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CHoUf 9?  of  ptygHtnana  anJi  ^urgrnna 


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Diseases  and  Deformities 

OF 

THE  FOOT 


BY 

JOHN  JOSEPH  NUTT,  B.L.,  M.D. 

Surgeon-in-Chief,  New  York  State  Hospital  for  the  Care  of 
Crippled  and  Deformed  Children;  Surgeon,  Sea 
Breeze  Hospital;  Assistant  Attending  Sur- 
geon, in  Charge  of  Orthopedic  Cases, 
Willard  Parker  Hospital;  Mem- 
ber of  the  American  Ortho- 
pedic Association. 


ILL  USTRA  TED 


NEW  YORK 
E.  B.  TREAT  &  COMPANY 

241-3    WEST    23  D    ST. 


Copyright,  1913, 
By  E.  B.  treat  &  CO. 


PREFACE 

This  handbook  is  prepared  for  the  use  oi  physicians 
who  have  not  had  the  time  or  the  opportunity  for  thor- 
ough study  of  this  often  neglected  subject  and  who'  feel 
keenly  their  inability  to  prescribe  scientifically  and  suc- 
cessfully for  the  many  who  consult  them  regarding  their 
pedal  conditions.  Textbooks  on  orthopedic  surgery  are 
rarely  consulted  by  the  general  practitioner,  as  most  of 
the  diseases  and  deformities  of  the  frame-work  of  the 
body  demand  such  treatment  as  only  orthopedic  surgeons 
are  prepared  to  give. 

With  regard  to  the  feet,  however,  much  of  the  treat- 
ment is  so  simple  that  the  general  practitioner  can  and 
should  assume  the  responsibility  of  preventing  deform- 
ities, correcting  abuses  and  those  conditions  which  have 
already  occurred  and  treating  minor  diseases  of  the  bones 
and  joints.  Many  painful  and  disagreeable  conditions, 
such  as  chilblains,  corns,  ingrowing  toe-nail,  painful  heel, 
excessive  sweating  of  the  feet,  etc.,  may  be  cured  by 
simple  measures,  and  these,  as  well  as  the  operations  for 
severer  complications,  are  herein  fully  described  and 
amply  illustrated. 

John  Joseph  Nutt,  M.  D. 

2020  Broadway,  New  York. 
Septemiber  lo,  1913. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesdeformitOOnutt 


CONTENTS 

CHAPTER  I 
ANATOMY 

PAGE 

Skeleton  of  the  Foot  —  Bones  —  Ligaments  —  Muscles 

and  Tendons  —  Nerves 13 

CHAPTER  II 

PHYSIOLOGY 

Distribution  of  Weight  —  Movements  —  The  Foot  at 
Rest  —  Standing  —  Work,  Rest,  Fatigue  — '  Walk- 
ing      41 

CHAPTER  III 

EXAMINATION 

Inspection  —  History  —  Palpation  —  Pain     .      .      .      .     59 

CHAPTER  IV 

SHAFFER'S    FOOT.      WEAK-FOOT..      FLAT-FOOT 

Shaffer's  Foot  —  Consequences  —  Symptoms  —  Eti- 
ology — ■  Treatment  —  Traction  Shoes  —  Opera- 
tion —  Weak-Foot  —  Characteristics  —  Results  of 
Non-Treatment  —  Treatment  —  Fiat-Foot  —  Os- 
seous Fiat-Foot  —  Pathology  —  Treatment  of 
Weak-Foot  and  Flat- Foot  —  Exercises  —  Arch 
Supporters  — '  Whitman's  Brace  —  Shaffer's  Brace 
—  Manipulations  —  Strapping  — Severe  Cases  — 
Plaster-of-Paris  Dressing  —  Tenotomy  — Excision 


CONTENTS 


PAGE 


—  Arthrodesis  —  Tarsectomy  —  Scaphoidectomy 

—  Post-Operative  Treatment  —  Liniments       .      .     64 

CHAPTER  V 

CONGENITAL  CLUB-FOOT 

Varieties  —  Frequency  —  Etiology  —  General  Appear- 
ance —  Explanation  of  Appearance  —  Changes  in 
the  Bones  —  Changes  in  Ligaments  and  Muscles 

—  Pathology  After  Use  —  Confirmation  of 
Structural  Changes .      .      .111 

CHAPTER  VI 
TREATMENT  OF  CONGENITAL  CLUB-FOOT 

Early    Treatment  —  Manipulation  —  Muslin    Bandage 

—  Adhesive  Plaster  — ■  Braces  —  Felt  Splint  — 
Wood  Splint  —  Plaster-of-Paris  —  Willard's  Shoe 

—  Taylor's  Brace  —  Deformity  in  the  Long  Bones 

—  Therapeutics  of  Early  Treatment  —  Treatment 
When  the  Child  Begins  to  Stand  —  Congenital  Tali- 
pes Equino- Valgus  —  Congenital  Talipes  Equinus 

—  Congenital  Talipes  Valgus  —  Congenital  Talipes 
Varus  —  Congenital  Talipes  Calcaneous  — Congeni- 
tal Talipes  Valgus  and  Varus  —  Congenital  Talipes 
Planus  —  Congenital  Talipes  Cavus  —  Congenital 
Talipes  Valgo-Cavus  —  Congenital  Talipes  Equino- 
Cavus  —  Operative  Procedures  in  the  Treatment  of 
Congenital  Club-Foot  —  Wolff's  Law  —  Davis' 
Law  —  Tenotomy  —  History  —  Value  —  Tendo 
Achillis  —  Posterior  Ligament  —  Tibialis  Posticus 

—  Astragalo-Scaphoid  Capsule  —  Flexor  Longus 
Digitorum  —  Tibialis  Anticus  —  Peroneus  Longus 
and  Brevis  —  Plantar  Fascia  —  Danger  of  Aneur- 
ism —  Indications  for  Tenotomy  —  Phelps'  Opera- 
tion —  Bone  Operations  —  Indications  —  Bones  to 
be  Attacked  —  Astragalectomy  —  Partial  Excision 

—  Ogston's    Operation  —  Cuneiform    Tarsectomy 

— I  Multiple  Cuneiform  Osteotamies       ....   125 


CONTENTS 

PAGE 

CHAPTER  VII 

POTTS'  PARAPLEGIA.  CEREBRAL  PARALYSIS 

Paralysis  Complicating  Pott's  Disease  —  Spastic  Pa- 
ralysis — •  Diagnosis  —  Examination  —  Treatment 

—  Tenotomies  —  Neurotomy — ^Injections  of  Alco- 
hol —  Stoeffel's  Technique 178 

CHAPTER  VIII 

INFANTILE  PARALYSIS 

Residual  Paralysis  —  Diagnosis  —  Recent  Cases  — 
Apparatus  —  Active  Movements  —  Massage  — 
Electricity  —  Heat  —  Functional  Use  —  Untreated 
Cases  of  Long  Standing  —  Valgus  —  Varus  — 
Equinus  —  Calcaneus  —  Cavus  —  Hollow  Claw- 
Foot  — '  Cases  of  Undoubtable  Permanent  Paraly- 
sis —  Reduction  of  Deformity  —  Recovery  of 
Muscles  — '  Braces  —  Tendon  Transplantation  — 
Astragalectomy 183 

CHAPTER  IX 

TUBERCULOSIS  AND  GONORRHEAL  DISEASE 

Tuberculous  Disease  of  the  Foot  —  Diagnosis  — ^  Dif- 
ferential Diagnosis  —  Immobilization  —  Campbell 
Braces  —  Thomas  Knee  Brace  —  Bier's  Treatment 

—  Tuberculin     Treatment  —  Heliotherapy  —  Sea- 
bathing —  Constitutional    Treatment  —  Operations 

—  Sinuses  —  Injections  —  Gonorrheal  Infection  of 

the  Foot  —  Treatment 217 

CHAPTER  X 

OTHER  AILMENTS 

Painful  Heel  —  Treatment  —  Operation  —  Metatarsal- 
gia  —  Treatment  —  Morton's  Toe  —  Treatment  — 
Hallux  Valgus  —  Treatment  —  Operation  —  Ham- 


CONTENTS 

PAGE 

mer-Toe  —  Treatment  —  Operation  —  Raynaud's 
Disease  —  Treatment  —  Myasthenia  Angio-Solero- 
tica  (Intermittent  Limping) — Treatment  —  Per- 
forating Ulcer  of  the  Foot  —  Treatment  —  Pernio 
( Chilblains )  —  Treatment  —  Congelation  ( Frost- 
Bite)  —  Treatment  —  Hyperidrosis  (Excessive 
Sweating)  —  Treatment  —  Erythromelalgia  — 
Plantar  Neuralgia  —  Clavus  (Corns)  — Treatment 
—  Paronychia  (Ingrowing  Toe-Nail) — Treat- 
ment —  Callosities  —  Painful  Soles        ....  248 

CHAPTER  XI 

FOOT  APPAREL 

Stockings  —  Shoes  —  Heels  —  Rocker  Sole  ....  2^]^ 


ILLUSTRATIONS 

PAGE 

Plate      I  Radiograph  of  a  Practically  Normal  Forefoot     i6 

"        II  Unilateral  Congenital  Talipes  Equino- Varus  120 

"       III  Flail  Ankle  Supported  by  Silk  Ligaments       .    184 

"       IV  Tuberculous  Disease  with  Old  Scars  .      .      ,   224 

FIG. 

1.  Axis  of  Ankle-joint  Movement 14 

2.  Trochlear  Surface  of  Astragalus 15 

3.  Three  Principal  Axes  of  Movements  of  the  Foot  25 

4.  Plantar  Flexion  in  Walking 31 

5.  Tibial  Flexion 44 

6.  Movements  at  the  Ankle-joint 45 

7.  Movements  at  the  Sub-Astragaloid  Joint    .  .      .46 

8.  Movements  at  the  Medio-Tarsal  Joint     ...  47 

9.  Standing  Positions 50 

10.  Heel-Walking 54 

11.  Toe- Walking 56 

12-14.  Effect  of  a  Shortened  Gastrocnemius       ...  65 

15-16.  Effect  of  a  Shortened  Gastrocnemius       .      .      .  ^J 

17-18.     Illustrating  Difficulty  in  Descending  Stairs  when 

Dorsal  Flexion  of  Foot  is  Limited    ...     69 

19-20.     Illustrating  Difficulty  in  Descending  Stairs  when 

Dorsal  Flexion  of  Foot  is  Limited    ...     70 


ILLUSTRATIONS 
FIG.  PAGE 

21.  Author's  Traction  Shoe 73 

22.  Author's  Traction  Shoe  in  Detail 75 

23.  Lengthening  the  Tendo  Achillis 'j'j 

24-25.  Adducted  and  Everted  Feet 79 

26.  Abducted  and  Everted  Feet  Seen  from  Behind  .  80 

27.  Abducted  and  Everted  Feet  Seen  from  in  Front  80 

28-29.  Advancement  of  the  External  Malleolus       .      ,  81 

30-31.  A    Shoe    Before   and   After    the    Insertion    of 

Wedges 87 

32-33.  Inverting  Heel 88 

34.  An  Exercise  for  Weak  Feet 90 

35.  The  Feet  at  Rest 91 

36.  Forcible  Correction  of  Abduction       ....  98 
37-38.  Adhesive  Plaster  Strapping 99 

39.  Manipulation  of  Metatarsal  Joints     ....  loi 

40.  Manipulation  of  the  Toe- Joints 102 

41-42.  The  Plaster-of-Paris  Bandage 104 

43.  Congenital  Talipes  Equino-Varus       ....  121 

44.  Manipulation  of  Congenital  Club-Foot  .      .      .  127 
45-52.  The  Judson  Club-Foot  Brace 132 

53.  The  Single  Steel  Bar  Brace,  First  Position  .      .134 

54.  The  Single  Steel  Bar  Brace,  Second  Position      .  135 

55.  The  Single  Steel  Bar  Brace,  Third  Position  .      .  136 

56.  The  Taylor  Club-Foot  Brace 141 

57.  The  Taylor  Club-Foot  Brace,  Applied     .      .      .  142 

58.  The  Taylor  Club-Foot  Brace,  Applied     .      .      .  147 


ILLUSTRATIONS 

FIG.  PAGE 

59.  The  Use  of  a  Wedge  in  Adduction     .      .      .      .155 

60.  Relapsed  Congenital  Talipes  Equino- Varus  .      .    159 

61.  Dangle-Foot 184 

62.  Paralytic  Talipes  Valgus 190 

63-65.     Examples  of  Equinus  Deformity 191 

66-68.     Varieties  of  Calcaneus 193 

69.  Paralytic  Calcaneus 194 

70.  Talipes  Plantaris 195 

71.  Talipes  Arcuatus 196 

72.  Paralysis  of  Anterior  Muscles 198 

y'i^.  Paralysis     of     Tendo     Achillis     and     Anterior 

Muscles 199 

74.  Paralysis  of  Posterior  and  Plantar  Muscles  .      .   200 

75.  Paralysis     of    All     Muscles     Except    Gastroc- 

Nemius  and  Soleus 201 

"jd.     Shaffer's  Lateral  Traction  Shoe 204 

'j'j.  Right- Angle  Stop  at  Ankle- Joint  .      .      .      .      .   206 

78.  Reverse-Stop  at  Ankle-joint 207 

79.  A    Stop-Joint    Allowing    a    Few    Degrees    of 

Motion  Only 207 

80.  Location  of  Ankle-Brace  Joint       .  >    .      .      .      .  208 

81.  Night-Shoe 211 

82.  Tuberculous  Foot 219 

83.  Campbell  Brace 228 

84.  Thomas  Knee-Brace 230 

85-86.  Transverse  Section  of  the  Forefoot  .      .      .      .251 

87.     Callus  in  Morton's  Toe 256 


ILLUSTRATIONS 
FIG.  ■  PAGE 

88.  Hallux  Valgus 258 

89.  Operation  for  Hallux  Valgus 260 

90.  Conservative  Treatment  of  Ingrowing  Toe-Nail  273 
91-92.  The  French  and  Cuban  Heels 280 

93.  A  Faulty  Shoe-Toe 281 

94-95.  The  Toe  of  the  Shoe \  282 

96.  An  Excellent  Shoe 282 

97-98.  Rocker-Sole  and  Flat-Sole  Shoe 284 

99-100.     Alterations  in  Length  of  Foot  During  Rest  and 

Weight-Bearing 285 

loi.     Alterations    in   Length    of    Foot    During    Tip- 
Toeing 286 


DISEASES  AND  DEFORMITIES 
OF   THE   FOOT 

CHAPTER  I 
ANATOMY 

THE   BONES 

The  bones  entering  into  the  formation  of  the  foot  are: 
the  astragalus,  the  os  calcis,  the  scaphoid,  the  cuboid,  the 
internal,  middle  and  external  cuneiforms,  the  five  metatar- 
sals, fourteen  phalanges  and  two  sesamoid  bones  under 
the  head  of  the  first  metatarsal.  Other  sesamoid  bones 
are  inconstant :  the  interphalangeal  one  of  the  great  toe 
is  found  in  about  50  per  cent,  of  cases  according  to  Pfitz- 
ner,  quoted  by  Dwight,  and  the  peroneum,  the  sesamoid 
in  the  tendon  of  the  peroneus  longus,  occurs  in  about  10 
per  cent.  (Dwight).  Variations  in  the  conformation  of 
the  bones  and  in  their  numbers,  changes  which  are  not 
pathological  but  which  may  have  important  bearings  on 
diagnosis  and  treatment,  have  been  studied  and  the  re- 
sults presented  in  book  form  by  the  late  Professor  Dwight 
of  Harvard  University. 

The  Astragalus  is  the  only  bone  of  the  foot  entering 
into  the  ankle  joint.     It  articulates  with  both  bones  of 

13 


"14     ■       DISEASES   AND   DEFORM'ITIES    OF   THE    FOOT 

r  n  ^  • 

the  leg.  Its  upper  articular  surface  is  convex  antero- 
posteriorly.  The  axis  of  the  chief  movement  in  which 
this  surface  enters,  that  is  to  say,  the  axis  of  the  most 
pronounced  movement  in  the  ankle  joint,  is  close  to  the 
calcaneo-astragaloid  joint.  It  passes  considerably  below 
the  internal  malleolus,  but  not  more  than  an  eighth  of  an 
inch  below  the  external  malleolus.  The  tip  of  the  ex- 
ternal malleolus  is  a  good  guide  to  this  axis.     How- 


Fig.  I.    Axis  of  Ankle-Joint  Movement 
The  transverse  axis  of  movement  at  the  ankle-joint  is  represented 
by  the  line  A-B.     It  is  at  the  tip  of  the  external  malleolus  and  not 
through  the  joint  surfaces  of  the  tibio-tarsal  joint. 

ever,  this  axis  is  not  stationary ;  its  outer  end  moves  for- 
ward during  plantar  flexion  and  backward  during  dorsal 
flexion.  Thus  the  outer  border  of  the  superior  articular 
surface  of  the  astragalus  has  two  movements :  the  one 
most  marked  of  rotation  about  a  transverse  axis  and  an- 
other, forward  and  inward  or  backward  and  inward, 
about  a  vertical  axis  situated  internal  to  the  internal  mal- 
leolar-astragaloid  articulation.     The  cause  of  these  two 


ANATOMY  IS 

movements  is  seen  in  the  shape  of  the  trochlear  surface: 
while  the  inner  edge  is  almost  completely  in  an  antero- 
posterior plane,  the  outer  edge  is  so  curved  that  it  lies  in 
a  plane  extending  downward  and  inward.  The  widest 
part  of  the  trochlear  surface  is  usually  somewhat  anterior 
to  the  center,  the  narrowest  being  at  the  posterior  ex- 
tremity. 


B 

Fig.  2.    Trochlear  Surface  of  Astragalus 
Left  astragalus,   from  above,   demonstrating  the   arc,   B-C,   of  a 
secondary  movement  at  the  ankle-joint  about  a  vertical  axis,  A. 

The  articular  surface  on  the  internal  surface  of  the 
astragalus  and  that  on  the  internal  malleolus  nearly  cor- 
respond in  size,  showing  that  there  is  slight  movement 
there  other  than  that  of  rotation  on  a  transverse  axis. 
The  articular  surface  on  the  external  surface  of  the  as- 
tragalus and  that  on  the  external  malleolus,  on  the  other 
hand,  do  not  correspond  in  size,  the  former  being  ex- 
tended much  further  antero-posteriorly  and  thus  permit- 
ting the  secondary  movement  about  the  vertical  axis  above 
described. 


1 6  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

There  is  no  lateral  movement,  no  movement  from 
side  to  side,  at  this  joint  except  when  the  narrowest,  the 
posterior,  portion  of  the  trochlear  is  presented  in  the 
mortice  formed  by  the  tibia  and  the  fibula.  When  the 
widest  part  of  the  trochlear  is  brought  directly  between 
the  malleoli  they  are  slightly  separated  and  the  inferior 
tibio-fibular  ligament  is  stretched. 

The  head  and  neck  of  the  astragalus  incline  inward 
toward  the  center  of  the  foot;  but  it  may  be  deformed 
and  incline  outward  toward  the  other  foot,  as  in  con- 
genital club-foot.  The  head  forms  the  ball  of  a  ball- 
and-socket  joint,  the  socket  being  formed  by  the  scaphoid, 
by  the  sustentaculum  tali  of  the  os  calcis,  and  by  the  cal- 
caneo-scaphoid  ligament. 

Below,  the  astragalus  articulates  with  the  os  calcis 
through  both  the  body  and  neck,  the  two  joints  being 
separated  by  the  interosseous  ligament.  The  synovial 
membrane  of  the  posterior  joint  is  separate  from  that  of 
any  other,  while  that  of  the  anterior  communicates  with 
the  synovial  membrane  lining  the  astragalo-scaphoid 
joint. 

The  movements  permitted  between  the  astragalus  and 
the  OS  calcis  are  inversion  and  eversion  on  a  longitudinal 
axis  and  slight  rotation  on  a  vertical  axis.  The  move- 
ment on  an  antero-posterior  axis,  producing  inversion 
and  eversion,  turns  the  sole  of  the  foot  inward  and  up- 
ward or  outward  and  upward.  The  former  movement, 
inversion,  is  the  more  pronounced.  The  axis  of  this 
movement,  to  be  exact,  is  oblique;  extending  from  the 


Plate  I. — Radiograph  of  a  Practically  Normal  Forefoot 


The  slight  deviation  in  the  direction  of  the  distal  phalanges  of  the 
first,  fourth  and  fifth  toes  from  the  long  axes  of  their  metatarsals 
shows  that  the  foot-wear  has  not  always  been  the  best  fitting.  A 
properly  fitting  shoe  should  preserve  the  straight  alignment  of  the 
bones  of  the  toes  and  also  the  fan-like  expansion  of  the  outer 
metatarsals. 


ANATOMY  17 

upper  portion  of  the  head  of  the  astragalus  downward, 
backward,  and  outward.  The  rotation  through  the 
vertical  axis  turns  the  heel  inward  or  outward  and  the 
fore-foot  in  an  opposite  direction  on  an  horizontal  plane. 

The  Scaphoid  assists  in  forming  the  socket  for  the 
head  of  the  astragalus.  Anteriorly  it  articulates  with 
the  three  cuneiform  bones  and,  occasionally,  externally 
with  the  cuboid.  On  its  internal  surface  is  a  tuberosity 
to  which  is  attached  a  part  of  the  tibialis  posticus  muscle. 
This  tuberosity  is  an  important  landmark  in  studying 
deformities. 

The  Os  Calais,  or  calcaneum,  is  the  largest  bone  in 
the  foot.  Above,  it  articulates  with  the  astragalus;  an- 
teriorly, with  the  cuboid.  Movement  at  the  calcaneo- 
cuboid joint  is  almost  entirely  in  a  downward  and  inward 
and  in  an  upward  and  outward  direction.  This  joint 
has  a  synovial  membrane  separate  from  any  other  joint. 
On  the  inferior  surface  of  the  os  calcis  are  two  tubercles: 
an  inner  and  an  outer  one.  The  former  is  the  larger. 
When  the  bone  is  resting  on  a  flat  surface  its  long  axis 
is  directed  forward,  downward,  and  outward.  A  tuber- 
cle on  the  external  surface,  the  peroneal  tubercle,  is  sit- 
uated slightly  below  and  in  front  of  the  center  of  this 
surface  and  separates  two  grooves,  through  the  lower  of 
which  runs  the  tendon  of  the  peroneus  longus  muscle 
and  through  the  upper  the  tendon  of  the  peroneus 
brevis. 

The  Cuboid  articulates  with  the  os  calcis  pos- 
teriorly ;  with  the  two  outer  metatarsals  in  front ;  and,  in- 


l8  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

ternally,  with  the  external  cuneiform,  and  sometimes  with 
the  scaphoid.  Externally  it  presents  a  tuberosity  which 
is  close  to  a  groove  on  this  bone  for  the  tendon  oi  the 
peroneus  longus. 

The  Cuneiform  Bones. —  The  three  cuneiform  bones 
articulate  in  front  with  the  three  inner  metatarsals. 

The  Metatarsal  Bones. — Of  the  five  metatarsal 
bones,  the  first  is  the  strongest  and  the  shortest,  while 
the  second  is  the  longest. 

The  Sesamoid  Bones. — Under  the  metatarsal- 
phalangeal  joint  of  the  great  toe  are  the  two  sesamoid 
bones.  They  are  in  the  tendon  of  the  flexor  brevis  hal- 
lucis  and  are  united  by  a  transverse  ligament.  These 
bones  are  not  accidental  formations  due  to  pressure 
(Bell),  but  have  been  found  in  the  still-bom  baby 
(Cross).  They  are  essential  to  the  perfect  physiology 
of  the  foot. 

The  Phalanges. —  There  are  two  phalanges  for  the 
great  toe  and  three  for  each  of  the  others. 

Arches. — In  most  descriptions  of  the  foot,  the  bones 
are  divided  into  two  rows  and  described  as  forming 
arches.  Each  foot  is  spoken  of  as  forming  three  arches: 
an  inner  and  an  outer  longitudinal  arch  and  an  anterior, 
or  transverse,  arch.  None  of  these  arches  is  a  perfect 
arch  and  therefore  can  have  no  keystone.  In  fact,  noth- 
ing is  gained  by  trying  to  adopt  the  terms  of  an  engineer 
of  inanimate  structures. 

Skeleton  of  the  Foot. — If  the  articulated  bones  of 
a  foot  are  placed  upon  the  table,  it  will  be  seen  that  the 


ANATOMY  19 

foot  rests  upon  the  os  calcis,  through  its  internal  and  ex- 
ternal tuberosities,  and  upon  the  heads  of  the  five  metatar- 
sals. The  cuboid  on  the  outer  side  is  much  nearer  the 
table-top  than  is  the  scaphoid  or  the  internal  cuneiform 
on  the  inner  side.  Neither  the  scaphoid  nor  any  of  the 
cuneiforms  nor  the  cuboid  reach  the  plane  on  which  rests 
the  OS  calcis  and  the  heads  oi  the  metatarsals.  The 
lower  edge  of  the  tubercle  of  the  scaphoid  is  slightly- 
above  a  line  connecting  the  posterior  edge  of  the  internal 
malleolus  and  the  inferior  tubercle  on  the  head  of  the 
first  metatarsal.  Attention  has  been  drawn  to  this  rela- 
tion by  Feiss. 

Just  back  of  the  scaphoid  is  the  head  of  the  astragalus, 
with  which  it  articulates,  and  below  the  head  is  the  sus- 
tentaculum tali.  On  the  outer  side  of  the  os  calcis  is 
seen  the  peroneal  tubercle  and  on  the  outer  side  of  the 
cuboid  may  be  seen  the  groove  for  the  tendon  of  the 
peroneus  longus.  The  os  calcis  projects  backward  into 
what  is  called  the  tuberosity.  It  is  this  tuberosity  which 
forms  the  projection  of  the  heel,  and  therefore  when  the 
longitudinal  axis  of  the  os  calcis  is  altered,  as  it  is  in  a 
lowering  of  the  dome  of  the  foot,  then  the  prominence 
of  the  heel  is  altered.  Negroes  are  so  frequently  afflicted 
with  the  deformity  of  flat-foot,  in  which  the  axis  of  the 
OS  calcis  is  changed  from  forward,  downward,  and  out- 
ward to  a  direction  of  forward,  horizontal,  and  inward, 
and  in  consequence  have  such  prominent  heels  that  it  has 
been  mistaken  for  a  characteristic  of  the  race,  instead  of 
a  characteristic  of  an  acquired  deformity. 


20  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

It  will  be  noted  that  the  medio-tarsal  joint  is  not  trans- 
verse to  the  long  axis  of  the  foot:  it  lies  in  a  plane  which 
is  oblique  from  within,  outward  and  backward.  There 
are  only  two  bones  in  the  foot  back  of  this  joint:  the  os 
calcis,  articulating  with  the  cuboid,  and  the  astragalus, 
articulating  with  the  scaphoid.  In  front  of  the  medio- 
tarsal  joint,  the  cuboid  and  the  scaphoid  are  not  side  by 
side;  the  three  cuneiforms  articulate  with  the  scaphoid 
anteriorly  and  the  cuboid  articulates  with  the  external 
cuneiform. 

The  five  metatarsals,  lying  side  by  side,  form  a  dome, 
convexity  upward,  much  like  that  which  is  formed  by  the 
metacarpals  when  the  hand  is  cupped.  The  two  outer 
metatarsals  articulate  with  the  cuboid  and  the  three  inner 
ones  with  the  cuneiforms.  There  is  less  movement  be- 
tween the  middle  metatarsal  and  the  ones  on  either  side 
of  it,  than  there  is  between  the  other  metatarsal  bones. 

It  should  be  noticed  that  the  joints  between  the  heads 
of  the  metatarsals  and  the  first  phalanges  are  not  in  the 
same  plane.  The  first  two  joints,  those  of  the  great  toe 
and  of  the  second  toe,  have  their  transverse  axes  in  align- 
ment and  the  axes  of  the  outer  three  form  an  almost 
straight  line,  but  the  axes  of  the  outer  three  joints  is  di- 
rected obliquely  outward  and  backward  from  the  axis  of 
movement  of  the  two  inner  joints.  The  latter  axis  is 
nearly  at  a  right  angle  to  the  longitudinal  axis  of  the 
foot. 

The  first  metatarsal  bone  is  conspicuously  larger  than 
any  of  the  other  metatarsals.     In  fact,  there  is  reason  for 


ANATOMY  21 

considering  it  the  first  phalanx,  but  all  we  need  to  notice 
here  is  that  it  is  a  very  strong,  stout  bone. 

The  sesamoid  bones  under  its  head  prevent  pressure  on 
the  tendon  of  the  flexor  longus  poUicis  while  the  foot  is 
weight-bearing,  so  that  that  tendon  is  always  free  to 
move.  These  bones  also  permit  the  head  of  the  meta- 
tarsal to  be  moved  under  the  same  conditions.  Upon 
assuming  the  position  of  tip-toe,  abduction  takes  place  at 
this  joint,  the  large  toe  being  moved  away  from  the 
others. 

THE  LIGAMENTS 

The  ligaments  are  very  numerous  between  the  bones  of 
the  foot. 

Plantar  Fascia. — Among  these  might  be  included 
the  plantar  fascia,  as  it  has  a  ligamentous  action  among 
its  other  functions.  No  one  can  see  this  fascia  without 
being  impressed  with  its  remarkable  strength.  It 
stretches  from  the  tuberosities  of  the  os  calcis  forward 
to  the  heads  of  the  metatarsals  and  the  first  phalanges. 
It  is  made  of  white  fibrous  tissue  containing  many  fat 
cells.  To  it  is  attached  the  plantar  skin,  which,  there- 
fore, does  not  move  upon  it  as  does  the  palmar  skin  on 
its  fascia.  The  upper  or  deep  surface  of  this  fascia  sends 
layers  to  the  bones  to  form  compartments  for  the  mus- 
cles, nerves,  and  vessels. 

Plantar  Ligaments. — On  the  plantar  surface,  there 
are  two  true  ligaments  of  large  size :  the  long  and  the 
short  plantar  ligaments.     They  extend  from  the  os  calcis 


22  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

forward,  the  shorter  to  the  part  of  the  cuboid  behind  the 
obhque  ridge,  the  longer  to  this  ridge  and,  by  some  of  its 
fibers,  to  the  metatarsal  bones.  Thus  this  long  plantar, 
the  long  inferior  calcaneo-cuboid  ligament,  encloses  the 
peroneal  groove  and  forms  a  canal  for  the  tendon  of  the 
peroneus  longus. 

On  the  dorsum  of  the  foot  there  are  the  dorsal  liga- 
ments of  each  joint,  but  none  of  these  demands  our  spe- 
cial attention. 

External  Lateral  Ligament. — On  the  outer  side  of 
the  foot  the  lateral  ligament  of  the  ankle  joint  is  strong 
and  important.  It  may  be  divided  into  three  slips :  the 
one  most  anterior,  extends  from  the  anterior  border 
of  the  malleolus  forward  and  inward  to  the  astragalus; 
the  middle  slip  extends  from  the  outer  surface  of  the 
malleolus,  close  to  its  apex,  to  the  tubercle  on  the  outer 
surface  of  the  os  calcis, —  this  part  of  the  ligament  is 
crossed  by  the  tendon  of  the  peroneus  brevis;  the  pos- 
terior slip  arising  from  the  posterior  border  of  the  mal- 
leolus and  attached  at  its  other  end  tO'  the  astragalus  close 
to  the  articular  facet  for  the  fibula. 

Internal  Lateral  Ligament. — On  the  inner  side  of 
the  foot  are  two  ligaments  of  the  greatest  consequence  in 
many  deformities  of  the  foot.  They  are  the  internal 
lateral  ligament  of  the  ankle  and  the  inferior  calcaneo- 
scaphoid  ligament.  The  internal  lateral  ligament  of  the 
ankle,  the  deltoid  ligament,  is  attached  to  the  internal 
malleolus  above,  while  below  its  attachments  are:  behind 
to  the  astragalus,  in  the  middle  to  the  astragalus  and  to 


ANATOMY  23 

the  sustentaculum  tali,  and  in  front  to  the  calcaneo- 
scaphoid  ligament  and  to  the  scaphoid  bone.  It  is  prob- 
ably this  ligament  which  offers  greater  resistance  to  the 
correction  of  congenital  club-foot  than  any  other  struc- 
ture exclusive  of  bone. 

Calcaneo-Scaphoid  Ligament. —  The  calcaneo- 
scaphoid  ligament  is  an  exceedingly  strong,  thick  liga- 
ment extending  from  the  sustentaculum  tali  to  the  sca- 
phoid. As  in  some  positions  it  supports  the  head  of  the 
astragalus,  it  has  been  called  the  suspensory  ligament; 
but  it  is  worthy  of  emphasis  that  this  ligament  must  be 
less  of  a  factor  in  supporting  the  astragalar  head  when 
the  scaphoid  is  rotated  downward, —  as  when  the  foot  is 
on  the  ground  and  the  toes  are  turned  outward, —  than 
when  the  foot  is  adducted,  for  the  ligament  is  then  re- 
laxed. 

Posterior  Ligament. — The  posterior  ligament  of 
the  ankle  joint,  the  posterior  tibio-astragaloid  ligament, 
may  be  an  important  factor  in  preventing  full  dorsal 
flexion  at  this  joint.  It  lies  in  front  of  the  narrowest 
part  of  the  tendo  Achillis,  opposite  the  thickest  part  of 
the  internal  malleolus,  and  is  easily  divided  through  the 
same  puncture  made  by  the  tenotome  for  division  of  the 
tendo  AchiUis. 

MUSCLES  AND  TENDONS 

It  is  well  to  remember  in  studying  muscles  that  though 
the  name  of  the  muscle  will  often  indicate  one  action  of 
which  it  is  capable  it  is  by  no  means  its  only  action.    Most 


24  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

of  the  muscles  of  the  foot  cross  several  joints  and  each 
one  of  these  joints  is  affected  by  contractions  of  the  mus- 
cles crossing  it.  Therefore  a  study  of  the  physiology  of 
these  muscles  is  by  no  means  a  simple  matter.  Then, 
too,  a  muscle  or  a  group  of  muscles,  acting  unopposed 
will  produce  one  set  of  movements,  while  if  opposed  by 
the  action  of  another  muscle,  or  muscular  group,  a  dif- 
ferent set  of  motions  will  be  produced.  It  is  an  impos- 
sibility for  any  muscle  of  the  foot  to  produce  a  movement 
confined  to  any  one  joint,  unless  its  action  is  counteracted 
in  part  by  one  or  more  other  muscles.  Thus  flexion  or 
extension  of  the  ankle  is  not  a  simple  movement:  some 
movement  takes  place  in  at  least  the  sub-astragaloid 
joint.  Under  normal  conditions  almost  every  joint  in 
the  foot  is  affected  by  the  movement  in  any  one  joint. 
It  is  this  close  association  of  joint  movements  which 
makes  analysis  of  the  movements  difficult.  For  instance, 
rotation  on  a  vertical  axis  takes  place  both  in  the  sub- 
astragaloid  and  in  the  medio-tarsal  joints,  and  so  does 
rotation  on  an  antero-posterior  axis. 

However,  it  simplifies  our  study,  if,  with  this  in  mind, 
we  consider  the  chief  axes  of  the  movements  of  the  foot 
to  be  three:  one  transverse,  for  flexion  and  extension 
through  the  ankle  joint;  one  antero-posterior,  passing 
through  the  sub-astragaloid  joint,  for  inversion  and  ever- 
sion  of  the  sole;  and  one  vertical,  through  the  medio- 
tarsal  joint,  for  abduction  and  adduction  of  the  fore- 
foot. 

Calf    Muscles. — The    calf    muscles    consist    of   the 


ANATOMY 


25 


gastrocnemius,  the  soleus,  and  the  plantarus.  The  last 
is  a  small  muscle,  seldom  inserted  into  the  plantar  fascia, 
but  usually  into  the  os  calcis  with  the  tendo  Achillis. 
The  gastrocnemius  and  the  soleus  have  very  large  bellies 
which  form  the  greater  part  of  the  calf.  If  the  other 
muscles  of  the  back  of  the  leg  are  undeveloped,  the  lower 


Fig.  3.  The  Three  Principal  Axes  of  Movements  of  the  Foot 
They  are  transverse,  longitudinal  and  vertical.  The  transverse  is 
shown  in  cross-section  on  the  astragalus.  It  should  be  placed  nearer 
the  sub-astragaloid  joint.  It  is  here  that  the  movements  of  the 
ankle,  dorsal  and  plantar  flexion  take  place.  The  longitudinal  is 
parallel  w^ith  the  long  axis  of  the  foot,  through  the  sub-astragaloid 
joint.  Motion  here  is  in  the  direction  of  inversion  and  eversion  of 
the  sole.  The  vertical  is  through  the  medio-tarsal  joint,  vv^ith  motion 
producing  abduction  and  adduction  of  the  fore-foot. 

third  of  the  leg  appears  very  small  and  the  calf  seems 
situated  higher  up  than  normally.  The  leg  of  the  danc- 
ing girl,  with  the  muscles  all  well  developed,  is  much 
more  graceful  than  the  leg  of  the  laborer,  whose  gas- 
trocnemius and  soleus  are  out  of  all  proportion  to  the 
development  of  the  other  muscles. 


26  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

The  gastrocnemius  is  attached  above  to  the  femur  and 
below  to  the  os  calcis  through  the  tendo  Achillis,  com- 
mon to  it  and  the  soleus.  Thus  the  influence  of  this 
muscle  is  felt  in  three  joints:  the  knee,  the  ankle,  and 
the  sub-astragaloid.  The  muscle  is  stretched  to  its  great- 
est extent  when  the  knee  is  fully  extended,  the  ankle  dorsal 
flexed,  and  the  foot  inverted.  If  the  knee  is  flexed,  the 
dorsal  flexion  and  the  inversion  can  be  increased.  There- 
fore in  testing  the  length  of  this  muscle  it  is  essential  that 
the  knee  be  in  extension.  The  soleus  is  attached  tO'  both 
the  leg  bones  and  to  the  tendo  Achillis. 

Tendo  Achillis. —  The  tendo  Achillis  is  not  inserted 
directly  into  the  posterior  part  of  the  os  calcis,  but  its 
fibers  should  be  considered  as  passing  around  the  tuber- 
osity into  the  plantar  surface,  although  these  fibers  are 
more  or  less  ossified.  Thus  the  force  exerted  through 
this  tension  is  more  of  a  lifting  and  a  thrusting  forward 
than  of  a  direct  pulling  upward.  The  insertion  of  the 
tendon  is  not  exactly  in  coincidence  with  the  long  axis 
of  the  OS  calcis,  but  is  slightly  to  the  inside,  so  that  it 
has  a  tendency  to  turn  the  ankle  outward  and  to  invert 
the  sole  of  the  foot  when  drawn  on  by  contraction  of 
the  calf  muscles.  Thus  it  will  be  seen  that  the  muscular 
action  serves  to  emphasize  that  outward  thrust  of  the 
ankle,  when  the  weight-bearing  foot  is  raised  on  tip-toe, 
which  must  take  place  on  account  of  the  shape  of  the 
trochlear  surface  of  the  astragalus  and  to  which  atten- 
tion has  been  called  in  discussing  that  bone. 

Between  the  tendo  Achillis  and  the  posterior  part  of 


ANATOMY  27 

the  tuberosity  is  a  bursa  which  is  subject  to  injury  and 
disease. 

The  narrowest  part  of  the  tendo  Achillis  is  one  and 
one-half  inches  above  the  heel,  at  a  point  about  opposite 
the  thickest  part  of  the  internal  malleolus,  and  here  it  is 
not  closely  associated  with  important  structures  and  is 
therefore  the  site  of  selection  for  subcutaneous  tenotomy. 

Peronei.— The.  two  peroneal  muscles  have  attach- 
ment to  the  fibula,  their  tendons  passing  downward  be- 
hind and  close  to  the  external  malleolus.  The  tendon 
of  the  brevis  lies  in  front  of  the  tendon  of  the  longus 
in  this  location.  On  the  outer  surface  of  the  calcaneum 
the  brevis  lies  above  the  longus  and  here  they  are  sep- 
arated by  the  peroneal  tubercle.  Here  each  tendon  has 
its  separate  synovial  sheath.  The  brevis  is  inserted  into 
the  fifth  metatarsal.  The  longus,  at  the  tubercle  of  the 
cuboid,  enters  the  groove  on  that  bone  and  runs  diago- 
nally forward  and  inward  to  be  inserted  into  the  outer 
surface  of  the  base  of  the  first  metatarsal  and  the  cor- 
responding surface  of  the  internal  cuneiform  close  to  the 
cuneiform-metatarsal  joint. 

The  action  of  these  two  muscles  is  to  plantar-flex  the 
ankle,  to  evert  the  foot  on  the  longitudinal  axis  passing 
through  the  sub-astragaloid  joint  and  to  abduct  the  fore- 
foot on  the  vertical  axis  passing  through  the  medio- 
tarsal  joint.  The  brevis  has  a  very  weak  abducting  ac- 
tion, but  greatly  strengthens  the  calcaneo-cuboid  joint  and 
slightly  flexes  it.  The  longus  draws  the  inner  border  of 
the  foot  toward  the  cuboid  and  heightens  and  greatly 


28  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

strengthens  the  dome  of  the  foot.  Furthermore,  in  this 
action  it  rotates  the  inner  cuneiform  and  the  first  meta- 
tarsal inward,  and  thus  crowds  upward  and  outward  the 
scaphoid,  which  in  its  turn  brings  a  pressure  to  bear 
against  the  head  of  the  astragalus.  It  should  be  noted 
well  that  the  peroneus  longus  can  act  much  better  in 
holding  down  the  forefoot  and  in  strengthening  the  dome 
if  the  foot  is  in  adduction  rather  than  abduction. 

Structures  at  the  Inner  Ankle. —  Behind  the  inner 
malleolus  pass  the  tendons  of  three  muscles  together  with 
the  posterior  tibial  vessels  and  nerve.  Just  back  of  the 
thickest  part  of  the  malleolus  these  structures  lie  in  the 
following  order:  close  to  the  bone,  the  tendon  of  the 
tibialis  posticus;  next,  that  of  the  flexor  longus  digi- 
torum;  then  a  vein,  the  artery,  and  the  other  vein;  then 
the  posterior  tibial  nerve;  and  finally  the  tendon  of  the 
flexor  longus  pollicis.  The  first  letter  in  each  word  in 
the  following  sentence  corresponds  with  the  first  letter 
in  the  name  of  each  structure  in  its  proper  order,  as  is 
known  to  many  students :  Timothy  doth  vex  all  very 
nervous  people. 

Flexor  Longus  Pollicis. — This  muscle  arises  from 
the  fibula.  Passing  downward,  its  tendon  enters  the 
outer  groove  on  the  back  part  of  the  tibia;  then  passes 
between  two  tubercles  on  the  posterior  surface  of  the 
astragalus  and  turning  inward  and  forward  passes  under 
the  sustentaculum  tali;  next  crosses  the  tendon  of  the 
flexor  longus  digitorum,  passing  above  it;  and  proceeds 
forward  between  the  sesamoid  bones  under  the  head  of 


ANATOMY  29 

the  first  metatarsal  to  be  attached  to  the  base  of  the  sec- 
ond phalanx. 

Action  of  this  muscle  produces  at  the  ankle  joint 
plantar  flexion;  at  the  subastragaloid,  slight  inver- 
sion; at  the  medio-tarsal,  slight  adduction;  and  flexion 
at  the  astragalo-scaphoid,  the  scapho-cuneiform,  the 
cuneiform-metatarsal  and  the  metatarsal-phalangeal 
joints.  If  the  great  toe  is  held  rigid  against  the  ground 
by  the  action  of  the  short  plantar  muscles  attached  to  it 
and  by  the  weight  of  the  body  and  the  heel  be  raised, 
contraction  of  the  flexor  longus  pollicis  will  throw  the 
ankle  outward  and  forward  and,  by  flexion  of  the  above- 
mentioned  joints,  will  raise  the  vault  and  shorten  the 
distance  between  the  heel  and  the  toe.  In  this  position 
of  the  weight-bearing  foot,  the  great  toe  is  drawn  away 
from  the  other  toes  and  rotated  upon  its  longitudinal 
axis.  Under  ordinary  conditions  flexion  of  the  first 
phalanx  is  prevented  by  the  action  of  the  flexor  brevis, 
the  abductor,  and  the  adductor  pollicis.  If  the  extreme 
tip-toe  position  is  assumed  and  the  last  phalanx  only  is 
on  the  ground,  the  position  habitually  used  in  dancing 
the  ballet,  the  metatarsal-phalangeal  joint  rides  on  the 
tendon  of  the  flexor  longus  pollicis  and  the  sesamoids 
are  lifted  from  the  supporting  surface. 

Contraction  of  the  flexor  longus  pollicis,  therefore, 
does  not  flex  the  great  toe  unless  it  is  desired  to  grasp 
something,  and  "  grasping  is  not  a  function  of  the  great 
toe  when  it  is  exerting  its  greatest  strength."  When  the 
foot  is  at  rest  the  metatarsal-phalangeal  and  the  inter- 


30  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

phalangeal  joints  may  easily  be  flexed,  but  the  foot  in 
action,  or  ready  for  action  as  in  assuming  a  position  for 
springing,  has  the  first  phalanx  held  securely  against  the 
metatarsal  and  the  inter-phalangeal  joint  equally  im- 
mobilized. In  this  respect  the  great  toe  is  in  strong  con- 
trast to  the  other  toes;  under  contraction  of  their  com- 
mon flexor  they  flex  at  their  first  inter-phalangeal  joints 
and  extend  at  the  distal  joints,  the  flexor  surface  of  the 
last  phalanx  being  held  against  the  ground,  but  the  proxi- 
mal inter-phalangeal  joint  being  raised,  flexed.  These 
toes  may,  however,  for  prehensile  purposes  be  made  to 
flex  at  all  their  points,  but  that  is  not  their  strongest  nor 
their  usual  action.  It  will  be  seen  from  the  foregoing 
that,  in  order  that  the  flexor  longus  pollicis  may  act 
properly,  it  is  necessary  that  the  flexor  brevis,  the  ab- 
ductor, and  the  adductor  pollicis  act  normally.  A  pa- 
tient with  paralysis  of  these  small  plantar  muscles  but 
with  the  other  muscles  of  the  foot  and  leg  intact,  will 
complain  that  in  walking  it  is  difficult  to  raise  the  heel, 
that  he  must  bring  the  foot  forward  in  its  straight,  right- 
angled  position,  and  that  when  he  attempts  to  rise  on  tip- 
toe his  foot  feels  vei'y  weak.  He  may  not  be  able  to^  do 
so  at  all.  Upon  examination  it  will  be  seen  that  when 
he  rises  on  tip-toe,  the  great  toe  bends  up  and  flexes  at 
the  inter-phalangeal  joint.  Holding  this  joint  down  by 
finger-pressure  enables  the  patient  to  execute  the  tip-toe 
movement  more  easily.  It  is  likewise  essential  for  the 
normal  functionating  of  this  muscle,  that  the  metatarsal- 
phalangeal  joint  of  the  great  toe  be  normal.     Deformity, 


ANATOMY 


31 


such  as  hallux  valgus,  or  clothing  of  the  foot  which  pre- 
vents normal  movements,  especially  abduction,  must  in- 
terfere seriously  with  its  actions. 

A  word  further  is  needed  as  to  the  thrusting  out  of 
the  ankle  during  contraction  of  this  muscle  when  the  fore- 
foot is  held  immobile,  as  by  the  weight  of  the  body  in 


Fig.  4.    Plantar  Flexion  in  Walking 
Plantar  flexion  of  the  weight-bearing  foot,  in  standing  and  walk- 
ing, thrusts  the  ankle  upward,  outward  and  forward  as  the  fore- 
foot can  not  be  moved  downward,  inward  and  backward — the  direc- 
tion it  takes  when  the  free-foot  is  plantar  flexed. 

walking:  its  power,  together  with  that  of  the  flexor 
longus  digitorum  and  of  the  tibialis  posticus,  would  tend 
to  produce  this  movement,  as  they  are  all  on  the  inner 
side  of  the  joint;  but  the  greatest  factor  in  its  produc- 
tion is  the  formation  of  the  tibio-astragaloid  joint. 
With  the  forefoot  resting  on  the  ground,  the  movement 
producing  the  adduction  seen  in  extreme  flexion  of  the 


32  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

free  foot,  produces  the  outward  movement  of  the  ankle. 
This  turning  outward  of  the  ankle  when  the  heel  is  raised 
can  not  take  place  unless  the  feet  are  parallel  or  adducted, 
and  therefore  the  correct  understanding  of  this  move- 
ment and  its  mechanism  is  of  the  greatest  importance 
in  determining  the  proper  positon  of  the  feet  in  walking 
and  standing. 

A  common  idea  of  the  function  of  the  flexor  longus 
pollicis  is  expressed  in  Morris's  Anatomy :  "  A  strong 
flexor  of  the  last  phalanx  of  the  great  toe  and  of  great 
importance  in  walking,  as  it  presses  the  great  toe  firmly 
against  the  ground."  As  it  is  scarcely  ever  used  as  a 
flexor  of  the  great  toe,  flexion  should  not  be  considered 
as  one  of  its  prime  functions  and  though  the  muscle  is 
of  great  importance  in  walking  we  do  not  believe  it  is 
used  to  press  the  great  toe  against  the  ground  except, 
possibly,  just  before  the  heel  is  raised. 

The  Flexor  Longus  Digitorum  arises  from  the 
tibia  and  is  inserted  into  the  last  phalanx  of  each  of  the 
four  outer  toes.  As  the  tendon  passes  around  the  ankle, 
it  is  separated  from  the  tendon  of  the  flexor  longus  pol- 
licis by  the  nerve  and  the  artery  with  its  venae  comities, 
and  lies  close  to  and  on  the  outer  side  of  the  tendon  of 
tibialis  posticus.  That  is,  the  tendon  of  the  tibialis  pos- 
ticus lies  between  the  tendon  of  the  flexor  longus  digi- 
torum and  the  internal  malleolus.  From  this  point  it 
runs  forward,  outward,  and  downward  between  the  ab- 
ductor pollicis  and  the  flexor  brevis  below  and  the  ten- 
don of  the  flexor  longus  pollicis  above.     The  action  of 


ANATOMY  33 

this  muscle  is  to  assist  in  moving  the  ankle  upward,  for- 
ward, and  outward;  to  flex  and  to  adduct  the  forefoot  and 
to  flex  the  metatarsal-phalangeal  and  the  inter-phalangeal 
joints  of  the  four  outer  toes.  This  action,  however,  is 
modified  by  the  accessorius,  the  flexor  brevis,  and  the  lum- 
bricales. 

Accessorius. — -This  small  muscle  from  its  origin  at 
the  tubercles  of  the  os  calcis,  draws  directly  backward 
the  tendon  of  the  long  flexor  to  which  it  is  attached  at 
its  curved  position  in  the  plantar,  thus  altering  the  direc- 
tion of  its  force  from  one  of  marked  adduction  and  in- 
ternal rotation  to  one  more  nearly  in  line  with  the  long 
diameter  of  the  foot. 

Flexor  Brevis  Digitorum. —  By  its  insertion  into 
the  middle  phalanges  of  the  four  outer  toes,  this  muscle 
flexes  the  first  inter-phalangeal  joints  and  holds  the  sec- 
ond inter-phalangeal  joints  in  extension  when  the  foot  is 
weight-bearing. 

Lumbricales. —  They  arise  from  the  tendons  of  the 
flexor  longus  digitorum  and  are  inserted  into  the  tendons 
of  the  extensor  longus  digitorum  upon  the  dorsum  of  the 
first  phalanges  of  the  four  outer  toes.  Their  action  is 
to  extend  the  phalanges  and  thus  to  assist  in  holding  the 
plantar  surfaces  of  the  distal  phalanges  tO'  the  ground. 
They  will  also,  by  adducting  the  outer  three  toes  and  by 
abducting  the  second  toe,  tend  to  preserve  the  transverse 
arch.  They  also  assist  to  a  slight  extent  in  flexing  the 
metatarsal-phalangeal  joints  of  these  toes.  Thus  it  will 
be  seen  that  the  usual  action  of  the  flexor  longus  digi- 


34  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

toruni  is  not  to  flex  the  toes  as  though  about  to  grasp 
some  object, —  they  are  not  dug  into  the  ground  as  rep- 
resented by  some  sculptors, —  but  that  its  action  is  to  flex 
the  four  smaller  toes  at  their  first  inter-phalangeal  joints 
while  the  distal  phalanges  are  held  flat  against  the  ground. 
Tibialis  Posticus. — This  is  stronger  than  either  of 
the  other  muscles  passing  behind  the  inner  malleolus.  It 
arises  from  both  the  tibia  and  the  fibula,  its  tendon  pass- 
ing beneath  that  of  the  flexor  longus  digitorum  and 
reaching  the  innermost  groove  on  the  back  of  the  inter- 
nal malleolus.  It  then  passes  forward  to  be  inserted  into 
the  tuberosity  of  the  scaphoid.  Expansions  of  this  ten- 
don are  inserted  into  the  sustentaculum  tali;  the  three 
cuneiform  bones;  the  cuboid,  and  the  second,  third,  and 
fourth  metatarsals.  In  passing  from  the  groove  on  the 
tibia  the  tendon  passes  beneath  the  inferior  calcaneo-sca- 
phoid  ligament  from  which  it  is  separated  only  by  the 
synovial  sheath  of  the  tendon.  It  is  this  ligamentous 
support  to  the  astragalus  which,  according  to  some  sur- 
geons (Hancock),  is  the  influence  whereby  the  tibialis 
posticus  helps  to  preserve  the  normal  dome  of  the  foot. 
Undoubtedly,  when  one  is  standing,  especially  in  the 
vicious  position  of  abduction  of  the  forefoot,  this  tendon 
does  act  as  a  more  or  less  passive  support;  but  in  action, 
the  adduction  and  inversion  which  it  produces,  together 
with  flexion  of  the  medio-tarsal  joint,  so  opposes  any 
descent  of  the  head  of  the  astragalus  that  no  ligamentous 
action  is  present  or  necessary.  By  the  wide  extent  of  its 
insertion  into  the  under  surfaces  of  the  other  bones,  and 


ANATOMY  35 

especially  into  the  second,  third,  and  fourth  metatarsals, 
its  influence  in  preserving  the  transverse  arch  is  also  of 
importance. 

There  are  four  muscles  passing  from  the  front  of  the 
leg  across  the  ankle  to  the  foot.  They  are  the  tibialis 
anticus,  the  extensor  proprius  pollicis,  the  extensor  lon- 
gus  digitorum,  and  the  peroneus  tertius. 

Tibialis  Anticus. — This  muscle  arises  from  the 
upper  two-thirds  of  the  outer  surface  of  the  tibia.  When 
well  developed  it  may  project  in  advance  of  the  crest  of 
that  bone,  but  it  never  overlaps  it.  When  it  is  atrophied 
a  sulcus  may  be  felt  between  the  crest  and  the  muscle's 
belly.  Its  tendon  is  inserted  into  the  internal  cuneiform 
on  the  lower  part  of  its  internal  surface  and  into  the  ad- 
jacent part  of  the  first  metatarsal. 

The  action  of  the  tibialis  anticus  is  usually  described 
as  being  that  of  a  dorsal  flexor  of  the  ankle  and  at  the 
same  time  an  elevator  of  the  inner  border  of  the  foot. 
The  chief  cause  of  flat-foot  has  been  ascribed  to  over- 
work and  partial  paralysis  of  this  muscle  (L.  A.  Sayre). 
The  condition  of  this  muscle  is  undoubtedly  an  etiologi- 
cal factor  in  some  cases  of  flat-foot,  but  it  would  seem 
that  the  weakness  in  uncomplicated  conditions  is  due  to 
improper  use  of  the  muscle  rather  than  primarily  to  the 
muscle  itself,  and  the  improper  use  is  rather  a  lack  of 
work  than  over-work.  Its  action  at  the  ankle  is  to  lessen 
the  angle  between  the  foot  and  the  leg,  but  whether  this 
action  should  be  expressed  as  flexing  the  foot  or  as  flex- 
ing the  leg  depends  on  which  is  the  fixed  and  which  is 


36  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

the  movable  attachment.  This  question  will  be  referred 
to  again  in  discussing  the  succeeding  muscles.  Acting 
from  above  this  muscle  has  an  adducting  and  an  inward 
rotating  force  on  the  internal  cuneiform  and  the  first 
metatarsal  and  tends  to  cause  an  inversion  of  the  sole. 
The  changed  position  of  the  internal  cuneiform  and  of 
the  first  metatarsal  places  them  in  the  most  advantageous 
position  for  supporting  the  weight  of  the  body. 

The  Extensor  Proprius  Pollicis  arises  from  the 
fibula  and  is  inserted  into  the  first  and  second  phalanges 
of  the  great  toe. 

The  Extensor  Longus  Digitorum  arises  from  the 
fibula  and  partly  from  the  tibia  and  is  inserted  into  the 
three  phalanges  of  the  four  outer  toes  and  into  the  liga- 
ment over  the  metatarsal-phalangeal  joints. 

The  Peroneus  Tertius  arises  from  the  fibula  and  is 
inserted  into  the  fifth  metatarsal. 

These  muscles  on  the  front  of  the  leg  have  generally 
been  considered  as  acting  from  their  upper  attachments 
only.  The  names  of  two  of  them  imply  that  they  are 
first  of  all  useful  as  extensors  of  the  digits.  One  of  their 
functions  is  undoubtedly  to  hold  the  forefoot  and  the 
toes  in  extension  and  thus  to  give  a  firm  support  against 
which  the  posterior  muscles  may  act,  but  of  greater  im- 
portance is  their  function  of  flexing  the  leg  on  the  foot. 
It  can  not  truthfully  be  said  that  barefooted  people 
need  these  great  extensors  of  the  toes  —  and  the  same 
holds  true  for  the  long  flexors  —  and  that  modern  foot- 


ANATOMY  37 

wear  has  done  away  with  their  usefulness.  Those  who 
have  developed  the  prehensile  power  of  the  toes  have 
done  so  mostly  through  the  development  of  the  plantar 
muscles. 

Of  the  plantar  muscles,  the  accessorius  and  the  lum- 
bricales  have  been  described. 

The  Abductor  PoUicis  is  a  strong  muscle  inserted 
into  the  inner  part  of  the  lower  surface  of  the  base  of 
the  first  phalanx  of  the  great  toe  and  into  the  internal 
sesamoid  bone.  Its  action  is  to  flex  the  first  phalanx 
and  to  abduct  the  great  toe  (toward  the  middle  plane  of 
the  body).  This  action  will  draw  the  metatarsal  inward 
toward  the  other  foot  into  a  position  which  supports  the 
internal  cuneiform  and  the  scaphoid  to  the  best  advantage. 
Thus  it  produces  flexion  and  abduction  of  the  astragalo- 
scaphoid  and  of  the  cuneiform-metatarsal  joints,  but  its 
action  at  the  metatarsal-phalangeal  joint  is,  normally,  to 
support  that  joint  by  compressing  the  articular  surfaces 
strongly  together. 

The  Flexor  Brevis  Digitorum  is  a  comparatively 
weak  muscle.  It  is  inserted  into  the  middle  phalanx  of 
each  of  the  four  outer  toes  and  by  flexing  the  first  inter- 
phalangeal  joint  helps  to  hold  the  plantar  surface  of  the 
last  phalanx  to  the  ground  during  action  of  the  long 
flexor. 

The  Abductor  Minimi  Digiti  is  inserted  into  the 
base  of  the  fifth  metatarsal  and  into  the  first  phalanx  of 
the  little  toe.     Its  action  is  probably  to  assist  in  altering 


38  DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

the  weight-bearing  surface  of  the  ball  of  the  foot  to  ac- 
commodate it  to  uneven  surfaces  and  to  the  changing  po- 
sitions of  the  foot  in  walking  and  running. 

The  Flexor  Brevis  PoUicis  is  inserted  into  the  first 
phalanx  of  the  great  toe.  It  is  not  only  a  flexor  of  the 
metatarsal-phalangeal  joint,  but  a  slight  adductor  as  well, 
as  its  origin  from  the  cuboid  is  to  the  outer  side  of  the 
middle  line  of  the  foot.  Its  tendons  on  either  side  of 
the  head  of  the  metatarsal  are  attached  to  the  sesamoid 
bones  and  not  the  least  important  of  its  actions  is  to 
control  these  bones. 

The  Adductor  PoUicis  is  also  attached  to  the  first 
phalanx.  The  great  toe,  then,  has  three  strong  muscles 
to  the  first  phalanx.  Their  action  is  more  especially  to 
support  the  joint  strongly  when  the  long  flexor  is  con- 
tracted. The  abductor  is  larger  than  the  adductor  and 
abduction  is  the  more  important  of  the  two  movements 
in  altering  the  weight-bearing  surface,  in  preserving  the 
transverse  arch,  and  in  supporting  the  dome. 

The  Transversus  Pedis  is  a  small  muscle  which  as- 
sists the  abductor  minimi  digiti  in  adjusting  the  ball  of 
the  foot  to  the  varying  pressures. 

The  Interossei  consist  of  three  plantar  and  four 
dorsal  muscles.  Their  common  action  is  to  flex  the  first 
phalanges  and  to  extend  the  other  two  of  the  four  outer 
toes.  This  they  do  by  virtue  of  their  insertions  into  the 
first  phalanges  and  into  the  tendons  of  the  extensor 
longus  digitorum.  It  is  mostly  due  to  them,  assisted  by 
the  lumbricales,  that  the  toes  are  not  flexed  in  walking. 


ANATOMY  39 

The  Extensor  Brevis  Digitorum  is  the  only  muscle 
on  the  dorsum  of  the  foot.  Of  its  four  tendons,  the 
innermost  is  attached  tO'  the  first  phalanx  of  the  great 
toe  and  the  outer  three  to  the  tendons  of  the  extensor 
longus  digitorum  going  to  the  second,  third,  and  fourth 
toes.  The  obliquity  of  the  direction  of  these  three  outer 
tendons  assists  in  correcting  the  direction  of  pull  by  the 
tendons  of  the  extensor  longus  digitorum. 

NERVES 

The  nerve  supply  of  all  the  muscles  of  the  foot  comes 
from  two  main  trunks :  the  internal  and  the  external 
popliteals.  The  internal  popliteal,  as  such,  or  after  it  be- 
comes the  posterior  tibial  or  divides  into  the  internal  and 
external  plantars,  supphes  all  the  muscles  on  the  back 
of  the  leg  and  ah  the  plantar  muscles.  The  external 
popliteal,  after  dividing  into  the  anterior  tibial  and  the 
musculo-cutaneous,  supplies  the  muscles  on  the  anterior 
and  outer  surfaces  of  the  leg  and  on  the  dorsum  of  the 
foot. 

The  cutaneous  nerves  of  the  foot  are  derived  from  the 
long  saphenous,  a  branch  of  the  anterior  crural,  which 
descends  through  Hunter's  canal  and  becomes  subcuta- 
neous in  the  upper  part  of  the  outer  side  of  the  leg;  from 
the  short  saphenous,  which  is  formed  in  the  middle  of  the 
calf  by  branches  from  the  popliteals,  the  communicans 
tibiahs,  and  the  communicans  fibularis;  from  the  cutane- 
ous branch  of  the  musculo-cutaneous;  and  by  cutaneous 
branches   from  the  anterior  and  posterior  tibials.     The 


40  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

outer  border  of  the  foot  is  supplied  by  the  short  saphen- 
ous ;  the  inner  border  by  the  long  saphenous ;  both  ankles 
and  the  dorsum  by  the  musculo-cutaneous,  which  also 
supplies  the  dorsum  of  the  adjacent  sides  of  the  second, 
third,  and  fourth  toes.  The  adjacent  sides  of  the  first 
and  second  toes  are  supplied  by  the  anterior  tibial.  The 
sole  is  supplied  by  the  internal  plantar,  as  is  also  the 
inner  border  of  the  first  toe  and  the  adjacent  borders  of 
the  second,  third,  and  fourth  toes  and  the  structures 
about  the  nails.  The  external  plantar  supplies  the  adja- 
cent sides  of  the  fourth  and  fifth  and  the  outer  side  of 
the  fifth  toe. 


CHAPTER  II 
PHYSIOLOGY 

Distribution  of  Weight. —  A  study  of  the  structure 
of  the  bones,  and  especially  of  their  striae,  as  indicating 
the  direction  in  which  nature  is  prepared  to  receive  the 
stress  of  weight  and  power,  shows  that  the  greatest 
strength  of  the  astragalus  is  in  the  body  extending  to 
the  OS  calcis,  but  that  the  head  and  neck  are  exceptionally 
strongly  made.  A  comparison  of  the  internal  architec- 
ture of  the  head  of  the  astragalus  and  the  scaphoid  with 
that  of  the  bones  about  the  calcaneo-cuboid  joint  demon- 
strates that  the  former  are  fitted  to  receive  the  greater 
stress. 

When  the  tibiae  are  in  the  transverse  plane  of  the  body 
containing  the  center  of  gravity,  the  amount  of  weight 
transmitted  through  the  posterior  tubercles  of  the  os  cal- 
cis and  the  amount  transmitted  through  the  astragalo- 
scaphoid  articulation,  will  depend  on  the  flexion  of  the 
foot.  The  greater  the  dorsal  flexion,  the  greater  will  be 
the  weight  transmitted  through  the  os  calcis;  and  the 
greater  the  plantar  flexion,  the  greater  will  be  the  weight 
transmitted  through  the  scaphoid.  However,  it  must  be 
borne  in  mind  that  the  position  of  the  transverse  plane 
containing  the  center  of  gravity  will  influence  the  share 

41 


42  DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

of  the  weight  borne  by  any  particular  bone.  This  may  be 
easily  demonstrated  by  scales :  if  a  stand  is  erected  so  as 
to  be  contingent  to  and  level  with  the  scale-platform,  it 
will  be  readily  seen  that  moving  the  transverse  plane  ever 
so  slightly  changes  the  proportion  of  the  weight  passing 
through  the  forefoot  and  the  heel.  With  the  subject  so 
placed  that  the  heels  are  on  the  stand  and  the  forefoot 
rests  upon  the  scale-platform,  advancing  an  arm,  nodding 
the  head,  contracting  the  abdominal  muscles,  raising  the 
chest,  will  cause  an  alteration  in  the  reading  of  the  dial. 
It  is  hard  to  conceive  of  this  plane  remaining  unchanged 
for  any  length  of  time.  Though  a  man  weighing  150 
pounds  and  standing  in  low-heeled  shoes  may  be  said  to 
transmit  100  pounds  through  the  heels  and  50  pounds 
through  the  forefoot,  and  this  was  the  conclusion  reached 
by  Sampson  after  a  careful  mathematical  calculation,  it 
must  not  be  supposed  that  even  while  one  is  standing  the 
relation  of  these  two  weights  is  constant.  One  reaches 
forward,  leans  backward,  bends  the  neck,  makes  a  ges- 
ticulation,—  and  the  ratio'  between  the  weight  borne  by 
the  forefoot  and  that  borne  by  the  heel  must  suffer  al- 
teration. In  short,  no  ligament,  muscle,  or  bone  is  un- 
der a  constant  amount  of  strain  while  the  body  is  in  the 
upright  position.  The  sense  of  balance  will  cause  the 
plane  of  the  center  of  gravity  to  be  quickly  returned 
when  moved  from  its  normal  position;  but  changes  in 
the  amount  of  strain  borne  by  individual  bones,  liga- 
ments, and  muscles  will  have  occurred,  even  if  momen- 
tary, and  that  is  of  the  greatest  importance. 


PHYSIOLOGY  43 


MOVEMENTS 


The  arrangement  of  the  bones  of  the  foot  and  their 
pecuHar  shapes  have  caused  not  a  httle  controversy  as  to 
their  physiology.  The  only  movement  of  the  foot  which 
is  invariably  examined,  and  usually  imperfectly,  is  the 
movement  at  the  ankle  joint.  Were  the  foot  comparable 
to  the  rim  of  a  wheel,  as  Dr,  Holmes  pictured  it,  the  in- 
trinsic foot  movements  would  be  of  slight  value.  But 
as  every  joint,  with  its  every  movement,  is  essential  to 
the  perfect  usefulness  of  the  foot  and  as  knowledge  of 
these  structures  is  not  widespread  even  among  physi- 
cians, it  is  not  a  cause  for  astonishment  that  the  pseudo- 
scientist  has  found  the  field  of  aching  feet  an  especially 
profitable  one. 

Ankle-joint. —  The  most  marked  movement  at  the 
ankle  joint  is  that  of  flexion  and  extension.  To  avoid 
confusion  they  are  frequently  designated  as  dorsal  and 
plantar  flexion  respectively.  Dorsal  flexion  takes  place 
normally  to  20  degrees  beyond  a  right-angle  (18, 
Tubby:  15-20,  Whitman).  That  is,  with  the  foot  upon 
the  ground  the  leg  can  be  flexed  on  the  foot  until  it  forms 
an  angle  of  75  or  70  degrees  with  the  sole  of  the  foot. 
If  this  dorsal  flexion  is  limited,  as  when  the  tibia 
can  be  flexed  only  to  a  right-angle,  an  abnormal  condition 
exists  and  proper  functionating  of  the  foot  is  interrupted. 
Plantar  flexion  of  the  foot  is  more  free,  extending  to 
form  an  angle  of  about  150  degrees  with  the  leg.  As 
explained  in  the  chapter  on  anatomy,  these  are  not  the 


44 


DISEASES    AND   DEFORMITIES    OF   THE    FOOT 


only  movements  at  the  ankle.  Owing  to  the  convexity 
of  the  outer  border  of  the  trochlear  of  the  astragalus, 
the  anterior  portion  of  that  bone  is  turned  slightly  in- 
ward in  full  plantar  flexion  and  less  markedly  outward  in 
full  dorsal  flexion.     This  may  be  seen  in  the  outward 


Fig.  5.    Tibial  Flexion 
Dorsal  flexion  of  the  weight-bearing  foot  may  be  termed  tibial 
flexion.     Normally  the  leg  can  be  flexed  on  the  foot  to  form  an 
angle  of  75  degrees  with  the  ground. 


thrust  of  the  ankle  when  one  is  rising  on  tip-toe;  the 
weight  of  the  body  prevents  the  toes  being  carried  in- 
wards, and  therefore  as  plantar  flexion  progresses  the 
ankle  is  forced  outwards :  —  a  most  important  fact  to 
consider  when  studying  the  physiology  of  walking. 


PHYSIOLOGY 


45 


At  the  ankle  joint,  then,  there  is  normally  plantar  flex- 
ion with  adduction  and  dorsal  flexion  with  slight  abduc- 
tion. 


Fig.  6.    Movements  at  the  Ankle- Joint 
The  axis  of  these  movements  is  situated  one-half  an  inch  below 
the  internal  malleolus.    Dorsal  flexion  is  arrested  at  an  angle  of 
75  degrees  and  plantar  flexion  at  an  angle  of  150  degrees  with  the 
line  of  the  leg, 

Sub-astragaloid  Joint. —  The  chief  movements  at 
the  calcaneo-astragaloid,  the  sub-astragaloid  joint,  are 
inversion  and   eversion,  by  which  the  sole  is  made  to 


46 


DISEASES    AND    DEFORMITIES    OF    THE    FOOT 


look  inward  and  outward.  With  these  movements  there 
is  some  abduction  and  adduction,  some  rotation  about  a 
vertical  axis. 


Fig.  7.    Movements  at  the  Sub-Astragaloid  Joint 

Movements  at  this  joint  are  on  an  antero-posterior  axis,  in  the 
direction  of  inversion  and  eversion.  The  dotted  line  shows  range 
of  inversion  and  the  dashed  line  the  range  of  eversion. 


Medio-tarsal.— The  medio-tarsal  joint  comprises 
two  joints:  the  astragalo-scaphoid  and  the  calcaneo-cu- 
boid.  It  is  usually  spoken  of  as  one  and  is  called  the 
medio-tarsal  or  mid-tarsal  joint.  The  chief  movement 
here  is  about  a  vertical  axis  in  the  direction  of  abduction 
and  adduction.  With  this  there  is  some  rotation  on  an 
antero-posterior  axis,  producing  inversion  and  eversion, 


PHYSIOLOGY 


47 


and  also  some  movement  on  a  transverse  axis  producing 
flexion  and  extension. 

Anterior  to  the  medio-tarsal  joint,  the  arthrodial  joints 
have  only  slight  movements,  but  they  are  essential  to  the 
normal  use  of  the  foot.  The  metatarsal-phalangeal 
joints,  especially  the  first,  may,  by  an  abnormality,  cause 
serious  loss  of  function. 


Fig.  8.    Movements  at  the  Medio-Tarsal  Joint 
These   movements   are   chiefly  abduction   and   adduction  about  a 
vertical  axis.     The  dotted  line  shovi^s  range  of  abduction  and  the 
dashed  line  the  range  of  adduction. 


There  are,  then,  three  principal  axes  of  movement  in 
the  foot:  one,  transverse  through  the  lower  part  of  the 
astragalus,  where  most  of  the  extension  and  flexion  takes 
place;  one  horizontal,  or  nearly  so,  extending  antero- 
posteriorly  through  the  sub-astragaloid  joint,  where  in- 
version and  eversion  are  the  most  marked ;  and  the  third 


48  DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

axis,  vertical  through  the  medio-tarsal  joint,  where  ab- 
duction and  adduction  of  the  forefoot  are  the  most 
marked  movements.  Active  abduction  without  eversion 
or  active  adduction  without  inversion  is  very  limited,  al- 
though passively  they  may  be  demonstrated. 

Great-toe  Joint. —  The  first  metatarsal-phalangeal 
joint  is  deserving  of  special  notice.  It  is  a  condyloid 
joint,  but  motion  is  chiefly  in  a  plane  downward  and  in- 
ward, toward  the  middle  line  of  the  body,  away  from  the 
other  toes.  At  rest  the  toe  is  slightly  dorsal-flexed  and 
drawn  toward  the  other  toes.  In  the  active  position  it  is 
in  a  line  with  the  foot,  neither  flexed  nor  extended,  and  is 
abducted,  drawn  away  from  the  other  toes.  In  the  act- 
ing normal  foot,  therefore,  there  is  a  space,  a  separation, 
between  the  great  toe  and  the  second  toe.  This  altera- 
tion in  the  position  of  this  toe  during  rest  and  during 
activity  has  an  important  bearing  upon  the  causes  and 
cure  of  flat-foot  and  upon  the  designing  of  foot-wear. 

THE  FOOT  AT  REST 

With  all  the  muscles  at  rest  the  foot  is  plantar-flexed, 
adducted,  and  rotated  slightly  inward.  This  may  be 
seen  in  the  anesthetized  patient,  in  the  perfectly  relaxed, 
supine  position  and  in  the  crossed-leg  position.  During 
muscular  rest  there  is  ligamentous  strain  if  the  foot  is 
not  supported  by  some  extraneous  means.  The  plantar- 
flexed  position  will  not  cause  strain  of  the  plantar  liga- 
ments, but  of  the  dorsal  ligaments;  and  the  inward  ro- 
tation, while  relaxing  the  internal  ligaments,  will  strain 


PHYSIOLOGY  49 

the  external.  If  this  strain  is  allowed  to  continue  for 
a  prolonged  period,  the  ligaments  become  weakened  and 
more  and  more  strain  will  be  transferred  to  the  muscles. 
Some  changes  may  take  place  in  the  articulations,  the 
most  marked  being  the  prominence  on  the  dorsum  of  the 
trochlear  surface  of  the  astragalus,  due  to  the  exagger- 
ated plantar  flexion  of  that  bone.  This  passive  strain 
may  result  in  nothing  more  serious  than  a  weak-foot;  or 
a  peripheral  neuritis  or  even  a  paralysis  may  follow. 
During  a  protracted  illness  therefore  it  is  incumbent  on 
the  physician  to  see  that  measures  are  taken  to  prevent 
this  foot-drop  and  its  possibly  attending  evils.  In  the 
weakened  condition  of  all  the  body  structures,  including 
the  muscles  and  ligaments,  which  accompanies  protracted 
illness,  such  as  typhoid  fever,  as  well  as  when  the  muscles 
of  the  foot  and  leg  are  weakened  from  a  partial  or  com- 
plete paralysis,  some  means  should  be  taken  to  retain  the 
foot  at  about  a  right-angle  with  the  leg.  A  prolific  cause 
of  continued  paralysis  following  anterior  poliomyelitis  is 
this  passive  stretching  of  muscles;  this  subject  will  be 
taken  up  more  fully  when  that  disease  is  discussed. 

STANDING 

Were  the  foot  jointless  except  for  the  tibio-astrag- 
aloid  joint,  its  physiology  would  be  much  simpler  than  it 
is  with  its  no  less  than  thirty-eight  articulations.  Many 
indeed  use  the  foot  as  though  it  were  one  solid  mass  and 
more  than  one  surgeon  has  described  it  as  though  its  nor- 
mal movements  were  limited  to  flexion  and  extension  at 


50  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

the  ankle  joint.  Were  this  the  case  the  question  of  the 
best  standing  position  would  be  limited  to  the  best  geo- 
metrical figure  to  be  formed  by  the  two  feet;  their  dis- 
tance apart,  their  relation  to  each  other,  and  the  angle  the 
foot  should  form  with  the  leg.  There  can  be  no  doubt 
but  that  we  should  select  the  quadrilateral  rather  than  the 
trapezoid  figure  for  the  feet.  That  is,  we  should  have 
the  centers  of  the  balls  of  the  feet  and  the  centers  of  the 
heels   form  the  corners  of  a  square.     If  the  heels  are 


Fig.  9.    Standing  Positions 
Trapezoid  and  quadrilateral  bases  of  support.     The  former  is  de- 
cidedly  the   weaker,   not   only   mechanically   but   physiologically,   on 
account  of  the  weak  position  of  the  bones,  ligaments  and  muscles. 
(After  Ellis.) 

placed  nearer  together  and  the  toes  turned  outward,  a 
trapezoid  figure  is  formed,  which  is  a  decidedly  weaker 
base  for  support  than  the  square  (Ellis). 

To  bring  the  transverse  plane  containing  the  center  of 
gravity  of  the  body  over  the  strongest  part  of  the  bony 
structures  of  the  foot  and  to  preserve  it  there  with  the 
least  muscular  exertion,  we  should  place  the  foot  at  about 
a  right-angle  with  the  leg.  Thus  the  body  of  the  astrag- 
alus would  rest  mostly  on  the  os  calcis.     Even  with  the 


PHYSIOLOGY  51 

most  careful  balancing,  however,  a  condition  of  absolute 
equilibrium  could  be  retained  only  by  having  the  flexors 
and  the  extensors  of  the  ankle  in  almost  constant  action, 
correcting  the  positions  of  the  tibia  as  the  gravity-plane 
was  moved  backward  or  forward. 

Work,  Rest,  Fatigue. — ■  It  may  be  well  to  here  dis- 
cuss work,  rest,  and  fatigue.  If  the  muscles  as  described 
above  are  in  constant  action,  they  are  usually  given  credit 
for  continuous  work.  The  action,  however,  is  not, 
strictly  speaking,  constant;  it  is  intermittent.  Normal 
growth  of  a  healthy  muscle,  and  in  fact  of  every  physi- 
ological tissue,  demands  both  work  and  rest.  With  the 
former  alone,  fatigue  must  result;  and  with  the  latter 
alone,  atrophy.  Either  condition  may  be  produced  to 
a  serious  extent,  even  beyond  repair.  Fatigue  depends 
upon  the  relation  of  work  to  rest  and  is  very  variable. 
The  corresponding  muscle  in  different  individuals  varies 
in  a  wide  range  not  only  as  to  the  work  it  can  do  without 
rest  and  without  fatigue,  but  in  the  same  individual  this 
potentiality  must  be  affected  by  a  great  many  factors 
having  to  do  with  the  functions  of  other  tisues. 

In  proper  standing,  no  one  muscle  is  in  constant  action. 
The  amount  of  rest  each  muscle  enjoys  is  or  should  be 
quite  as  definite  as  the  amount  of  work,  and  in  a  healthy 
individual  fatigue  should  not  occur  within  a  reasonable 
time.  There  are  muscles  in  the  body  which  undergo  in- 
termittent contraction  for  most  of  the  waking  hours,  and 
some  muscles,  the  cardiac  for  instance,  work  and  rest 
for  the  lifetime  without  any  prolonged  rest. 


52  ,  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

The  foot  can  not  be  considered  as  a  solid  mass,  as 
though  it  were  composed  of  one  bone.  The  modern 
clothing  of  the  foot  hides  the  more  minute  movements 
from  view,  but  those  movements  are  none  the  less  made, 
and  if  they  are  prevented  or  even  limited,  the  mechanics 
of  the  foot  are  altered  and  a  weaker  organ  results. 
Whether  or  not  such  weakness  becomes  a  serious  disa- 
bility depends  upon  the  extent  of  the  interference  and 
upon  the  amount  the  confined  foot  is  used. 

If  the  foot  is  renting  on  the  ground  in  a  relaxed  con- 
dition and  is  called  into  action  by  one's  quickly  rising 
to  an  upright  position,  certain  changes  in  the  positions  of 
the  bones  take  place.  The  most  evident  of  these  is  the 
abduction;  —  toward  the  middle  hne  of  the  body,  to- 
ward the  other  foot  —  of  the  great  toe,  the  first 
metatarsal,  the  internal  cuneiform,  and  the  scaphoid. 
Whereas  in  rest  all  the  toes  are  in  contact,  a  space  is 
now  evident  between  the  first  and  second  toes.  With 
this  movement  there  also  occurs  a  rotation  of  the  same 
bones  upward  and  inward,  rotation  downward  on  that 
side  toward  the  middle  line  of  the  foot.  There  will 
also  be  an  increa'se  in  the  height  of  the  scaphoid  above 
the  ground  and  an  increase  in  the  height  of  the  dome, 
due  mostly  to  the,  abduction,  rotation,  and  slight  flexion 
of  the  joints  already  mentioned.  The  transverse  arch 
will  be  increased,  and  the  four  outer  toes  will  be  flexed 
at  their  first  inter-phalangeal  joints  and  extended  at  their 
distal  joints.  The  cuboid  will  be  slightly  flexed  and 
addiicted  and  there  will  be  some  flexion  at  the  two  outer 


PHYSIOLOGY  53 

scapho-cuneiform  articulations.  There  will  be  some  ro- 
tation inwards  on  a  vertical  axis  at  the  subastragaloid 
joint. 

These  movements  will  be  produced,  by  the  plantar 
muscles  abducting  the  first  phalanx  of  the  great  toe  and 
holding  it  firmly  against  the  metatarsal  and  the  ground; 
by  the  long  flexor  of  the  great  toe  acting  on  all  the  joints 
over  which  it  passes;  by  the  tibialis  anticus  drawing  up- 
ward and  rotating  inward  the  scaphoid  and  the  internal 
cuneiform;  by  the  tibialis  posticus  drawing  backward, 
flexing  the  scaphoid;  and  also  flexing  and  abducting  — 
drawing  away  from  the  middle  line  of  the  foot  —  all 
the  bones  to  which  it  is  attached  by  the  wide  expansion 
of  its  insertion;  by  the  long  flexor  of  the  toes,  which, 
while  pressing  the  distal  phalanges  to  the  ground,  as- 
sists the  tibialis  posticus  in  rotating  the  foot  inward  at 
the  sub-astragaloid  joint;  by  the  plantar  muscles  flexing 
the  joints  in  the  forefoot  and  thereby  increasing  the 
transverse  arch,  in  which  action  the  peroneus  longus 
plays  a  very  important  part.  The  foot  is  not  more  in- 
verted, the  forefoot  more  markedly  adducted,  and  the 
toes  crumpled  up  in  complete  flexion  because  the  peronei, 
the  small  adductor  of  the  great  toe,  the  long  extensors 
of  the  toes,  the  lumbricales  and  the  interossei  are  acting 
at  the  same  time.  The  importance  of  every  one  of  these 
muscles  is  seen  where  one  or  more  have  been  paralyzed. 


54 


DISEASES    AND    DEFORMITIES    OF    THE    FOOT 


WALKING 

The  question  of  what  may  be  called  the  physiological 
way  of  walking  can  be  determined  by  deciding  whether 
the  heel  or  the  toe  should  be  presented  first  to  the  ground. 
A  few  minutes'  observation  of  the  pedestrian  in  any 
large  city  will  convince  one  that  most  people  walk  on 
their  heels.  On  the  other  hand  no  runner  would  think 
of  letting  his  heels  touch  first.  The  athletic  trainer  is 
continually  cautioning  his  men  to  "  keep  up  on  your  toes." 


Fig.  io.    Heel-Walking 
The  feet  are  abducted;  toes  turned  outward.    This  is  conducive 
to  awkwardness,  fatigue,  weakness,  strain  and  deformity. 

Even  a  heel-walker  presents  his  toes  first  if  he  steps  down 
from  any  height,  as  from  a  high  curb.  No  one  would 
think  of  jumping  from  a  height  of  a  few  feet  and  land- 
ing on  his  heels.  Therefore  it  would  seem  to  be  quite 
evident  that  less  concussion  is  felt  and  more  spring  is 
obtained  by  presenting  the  toes  in  advance  of  the  heel. 
That  all  movements  are  more  gracefully  executed  with 
the  heels  off  the  ground  is  known  to  dancing-masters. 
Many  years  ago,  teachers  of  deportment  are  said  to  have 


PHYSIOLOGY  55 

adopted  a  novel  way  of  training  young  ladies  not  to 
walk  on  their  heels;  a  rubber  ball  having  a  whistle  at- 
tachment was  so  placed  in  the  heel  that  if  one  did  not 
walk  on  her  toes  in  crossing  the  ballroom  floor,  the  whistle 
sounded  at  each  step. 

To  the  conclusion  that  for  these  reasons  alone  walking 
should  be  done  on  the  toes,  one  might  reply,  however, 
that  walking  is  not  running,  nor  jumping,  nor  dancing. 
Yet  why  should  the  foot,  which  suffers  less  fatigue,  trans- 
mits less  shock,  and  gives  more  grace  when  the  toes  are 
brought  to  the  ground  in  advance  of  the  heel,  be  changed 
in  its  action  so  as  to  present  the  heel  first  when  walking? 
As  for  the  fatigue,  the  heel-and-toe  walking  is  a  far 
more  fatiguing  exercise  than  running,  according  to  the 
witness  of  those  who  have  entered  these  contests,  which 
are  rapidly  being  eliminated  from  athletic  programmes. 
As  for  the  shock,  it  may  be  very  slight  at  each  step ;  but 
that  there  is  a  shock,  which  is  felt  in  the  cord  and  brain 
is  quite  evidenced  by  the  toe-walking  temporarily  adopted 
by  anyone  suffering  with  a  severe  headache.  It  is  for 
the  lessening  of  this  concussion,  too,  that  rubber  heels 
are  worn.  As  for  the  grace,  no  comparison  is  necessary. 
Toe-walking  is  frowned  on  by  some  as  being  an  ex- 
pression of  affectation,  but  such  a  reason  for  ignoring 
physiological  laws  is  too  inane  for  discussion. 

Nevertheless  many  are  convinced  that  the  usual  man- 
ner of  walking  is  the  correct  one.  They  argue,  that  the 
heel  presentation  is  by  far  the  most  common ;  that  people 
adopt  it  without  being  taught;  and  that  in  bringing  the 


5.6 


DISEASES    AND    DEFORMITIES    OF   THE    FOOT 


foot  forward  it  seems  to  entail  less  effort  to  present  the 
heel.  Doctor  Holmes  represented  walking  by  a  wheel, 
the  legs  being  the  spokes  and  the  feet  representing  seg- 
ments of  the  rim.  Were  this  a  true  interpretation  of 
the  act,  the  heel  would  of  course  reach  the  ground  be- 
fore the  toes.  The  only  one  of  the  objections  which  is 
a  true  obstacle  to  the  general  adoption  of  toe-heel  walk- 
ing is  that  heel-toe  walking  is  so  very  common.     It  must 

^_^_<Od <Oo  — 


<3G^ 


CDD- 


Fig.  II.    Toe- Walking 
The  feet  are  directed  in  a  line  parallel  to  the  line  of  progression. 
The  toe  reaches  the  ground  slightly  in  advance  of  the  heel.     Dorsal 
flexion  of  the  back-foot  (flexion  of  the  leg)  takes  place  in  a  normal 
manner.    This  is  conducive  to  grace,  rest  and  strength. 

necessarily  be  a  slow  reformation  to  change  a  custom  so 
generally  adopted  by  all  civilized  races.  The  reason  that 
it  is  so  much  easier  to  walk  on  the  heels  rather  than  on 
the  toes  and  that  that  method  is  adopted  without  being 
taught,  is  because  of  the  heel  on  the  shoe.  With  a  high- 
heeled  shoe  it  is  impossible  to  plantarflex  the  foot  suffi- 
ciently to  walk  on  the  toes,  and  even  with  the  heel  but 
slightly  higher  than  the  sole,  it  is  difficult  to  prevent  it 
from  coming  in  contact  with  the  ground  first.     Fur- 


PHYSIOLOGY  57 

thermore,  it  is  impossible  to  walk  otherwise  than  heel  and 
toe  with  the  toes  pointing  outward,  as  is  still  so  com- 
monly done. 

Before  trying  to  walk  properly  one  must  learn  to  stand 
properly.  One  can  not  walk  on  the  toes  if  one  stands 
with  the  toes  turned  out.  Conversely,  it  is  much  more 
difficult  to  walk  on  the  heels  if  one  stands  with  the  feet 
parallel.  If  we  follow  the  physiological  action  of  walk- 
ing from  this  standing  position,  it  will  be  manifest  that 
the  toe  should  be  presented  to  the  ground  slightly  in 
advance  of  the  heel.  As  the  transverse  plane  of  the 
body  passes  over  the  foot,  the  anterior  muscles  of  the 
leg  are  contracting  and  flexing  the  tibia  on  the  foot,  the 
toes  being  held  against  the  ground  by  the  flexors,  as- 
sisted by  the  weight  of  the  body.  Then,  at  the  proper 
time,  the  gastrocnemius  and  the  soleus  lift  the  heel;  the 
muscles  passing  behind  the  inner  malleolus  contract  and 
the  smaller  toes  grasp  the  ground,  be  it  the  earth  or  the 
sole  of  the  shoe,  the  plantar  muscles  helping;  the  large 
toe  is  abducted  —  toward  the  middle  line  of  the  body  — 
rotated  and  held  firmly  against  the  ground  and  the  medio- 
tarsal  joint  is  flexed  and  adducted  —  not  by  movement 
of  the  forefoot,  but  by  the  lifting  upward  and  outward 
of  the  hind  foot.  The  muscles  passing  behind  the  outer 
ankle  contract  and  increase  the  height  of  the  dome  and 
prevent  an  exaggeration  of  the  adducting  action  of  the 
inner  muscles.  At  the  beginning  of  the  contraction  of 
the  posterior  muscles  the  anterior  muscles  relax.  When 
the  extreme  of  extension  of  the  foot  is  reached,  the  line 


58  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

of  the  heads  of  the  first  and  second  metatarsals  is  at  a 
right  angle  to  the  line  of  progression  of  the  body;  the 
arch  of  the  foot  is  increased  and  the  ankle  thrown  out- 
ward. Seen  from  behind,  the  toes  are  to  the  inner  side 
of  the  foot,  the  heel  being  about  in  a  line  with  the  third 
or  fourth  toe.  As  the  ground  is  spurned,  and  this  spurn- 
ing is  done  even  when  the  foot  is  clothed,  the  knee  is 
slightly  flexed  and  the  foot  carried  forward  over  the 
three  outer  toes  by  flexion  of  the  thigh  and  by  some 
rotation  of  the  pelvis  backward  on  the  opposite  side. 
Thus,  as  the  foot  is  brought  forward  all  of  its  muscles 
are  relaxed  and  it  is  in  the  position  of  rest,  the  position 
of  plantar  flexion  and  inward  rotation,  and  the  toes  are 
the  nearest  to  the  ground.  An  extraordinary  effort  will 
therefore  be  necessary  to  present  the  heel  first;  while,  if 
the  toes  are  to  receive  the  first  impulse  of  contact  with 
the  ground,  the  foot  can  be  allowed  simply  to  drop  when 
the  desired  location  is  reached.  To  walk  in  this  way 
with  the  toes  turned  outward  would  be  impossible.  This 
rest  of  the  foot  as  it  is  brought  forward  may  seem  to  be 
insignificant,  but  it  is  of  great  importance  in  preventing 
fatigue.  Emphasis  should  be  placed  on  the  fact  that  it 
is  only  in  walking  as  thus  described,  that  control  over 
the  exact  location  of  the  footfall  is  to  be  obtained.  In 
heel  presentation  it  is  impossible  to  recover  or  to  change 
the  footfall  after  the  heel  has  touched  the  ground.  No 
one  would  think  of  walking  over  a  surface  where  each 
step  had  to  be  chosen  with  care,  otherwise  than  on  the 
toes. 


CHAPTER  III 
EXAMINATION 

In  examining  a  foot  some  such  procedure  as  the  fol- 
lowing is  recommended.  By  using  it  in  detail  on  every 
occasion,  errors  in  diagnosis  are  less  likely  to  occur. 

Inspection. —  This  should  begin  with  the  patient's 
entrance  into  the  examining-room.  Is  there  a  limp?  Is 
the  foot  held  in  abduction?  Is  the  clothing  over  the 
internal  malleolus  worn?  Are  the  inner  ankles  promi- 
nent? When  the  patient  stands  are  the  feet  parallel  or 
divergent?  Are  the  soles  flat  on  the  ground  or  do  the 
toes  turn  upward?  Are  any  of  the  joints,  especially  the 
first  metatarsal-phalangeal,  prominent  through  the  shoe? 

History. —  Inspection  will  naturally  be  interrupted 
to  take  the  history.  Information  should  be  sought  re- 
garding recent  illnesses  and  injuries;  the  customary  use 
of  the  feet;  amount  of  standing,  walking,  dancing,  and  of 
any  athletic  sports.  How  long  ago  were  the  feet  per- 
fectly well?  How  did  the  present  trouble  begin?  Has 
the  patient  ever  experienced  it  before  and  entirely  re- 
covered from  it?  Is  the  complaint  that  of  fatigue  and 
weakness  or  of  pain?  Is  it  continuous  or  worse  at 
times?  If  the  latter,  what  seems  to  influence  it;  if  use, 
what  kind  of  use?     How  much  use?     Is  it  worse  at 

59 


60  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

night  or  in  the  morning?  Are  both  feet  affected?  Was 
one  affected  before  the  other?  Are  both  equally  affected 
now?  Family  and  personal  history  should  be  inquired 
into  for  any  trace  of  tuberculosis,  syphilis,  gonorrhea, 
or  rachitis.  Rheumatism  or  gout  may  play  an  important 
part  in  a  localized  foot  trouble.  Careful  inquiry  should 
be  made  into  any  previous  treatment,  whether  profes- 
sional or  that  of  some  member  of  the  laity,  as  this  in- 
formation will  frequently  help  in  determining  what  line 
of  treatment  the  patient  will  be  the  most  likely  to  follow 
where  there  is  some  choice  permissible. 

Both  feet  and  legs,  above  the  knees,  should  always  be 
bared  for  examination  in  every  instance.  First  inspect 
the  shoes :  locate  the  most  worn  parts  on  the  soles  and 
heels;  is  the  upper  stretched  so  as  to  overlap  the  sole  or 
heel  on  either  side?  Is  the  inner  side  of  the  sole  and 
heel  on  a  straight  line?  Compare  the  height  of  the  heel 
with  that  of  the  sole;  is  the  center  of  the  heel  under  the 
center  of  the  weight-bearing  part  of  the  hind  foot  ?  Then 
examine  the  stockings :  are  they  damp  ?  are  they  pointed  ? 
Before  their  removal  it  had  better  be  determined  whether 
they  constrict  the  toes.  Note  the  color  of  the  skin  for 
signs  of  faulty  blood  supply.  With  the  patient  standing, 
notice  the  position  of  the  toes :  are  they  flat  on  the  ground, 
flexed,  hyperextended,  parallel  ?  Is  there  a  hallux  valgus  ? 
Does  the  forefoot  appear  to  be  flattened  out,  —  extra 
wide?  Is  there  a  concavity  or  a  bulging  beneath  the 
tuberosity  of  the  scaphoid?  Are  the  malleoli  well  de- 
fined?    Does  the  outer  one  seem  to  be  in  its  normal  re- 


EXAMINATION  6l 

lation  to  the  inner  one  or  is  it  apparently  advanced? 
When  examined  from  behind,  do  the  tendo  Achillis  run 
down  vertically  to  the  calcaneum  or  do  they  incline  to 
one  side?  Are  the  normal  depressions  on  either  side  of 
the  heel-cord  present?  Does  the  heel  spread  out  on  all 
sides  like  an  inverted  mushroom?  Ask  the  patient  to 
rise  on  his  toes;  is  it  easily  done?  Does  the  dome 
heighten?  Are  the  ankles  thrown  upwards  and  out- 
wards? Can  the  patient  invert  the  feet  and  stand  on 
the  outer  borders? 

Palpation. —  Take  one  foot,  the  well  foot  first,  if 
only  one  is  complained  of,  on  your  knee  in  such  a  way 
that  the  entire  leg  is  comfortable  and  relaxed.  The  sur- 
geon's chair  should  be  a  few  inches  lower  than  the  one 
upon  which  the  patient  is  seated.  Note  by  feeling 
whether  the  local  temperature  is  normal.  Search  for 
evidences  of  uneven  pressure  or  of  friction,  such  as  cal- 
luses and  corns.  If  there  are  calluses  under  the  fore- 
foot, are  they  beneath  each  one  of  the  five  metatarsals 
or  beneath  only  the  middle  three?  Is  there  callous  for- 
mation along  the  outer  border  of  the  foot,  or  around 
the  margin  of  the  heel  ?  Is  there  a  bunion  over  the  first 
metatarsal-phalangeal  joint?  Are  there  ingrowing  toe- 
nails? Determine  the  condition  of  the  circulation  of  the 
foot.  With  a  skin  pencil  mark  the  lower  posterior  angle 
of  the  internal  malleolus,  the  tuberosity  of  the  scaphoid, 
and  the  inferior  external  tuberosity  on  the  head  of  the 
first  metatarsal.  A  straight  line  connecting  the  first  and 
last  of  these  points  should  have  the  tuberosity  of  the 


62  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

scaphoid  slightly  above  it.  The  tarso-metatarsal  joint 
of  the  first  toe  is  normally  at  mid-distance  of  the  inner 
border  of  the  foot  and  if  measuring  shows  a  lengthening 
of  the  posterior  half,  a  lowering  of  the  arch  exists  (Gold- 
ing-Bird).  If  deformities  of  the  toes  are  present, 
ascertain  if  they  can  be  easily  straightened  by  passive 
movements. 

Hold  the  calcaneum  firmly  in  one  hand;  with  the 
tuberosity  resting  in  the  palm,  grasp  the  bone  with  the 
thumb  and  fingers  so  as  to  prevent  its  moving,  and  with 
the  other  hand  test  the  motion  at  the  medio-tarsal  joint. 
Then  hold  the  leg  above  the  ankle  with  one  hand  and 
grasping  the  foot  about  the  medio-tarsal  joint  with  the 
other,  test  inversion  and  eversion.  Test  the  ankle  joint 
last:  in  so  doing  do  not  let  flexion  and  extension  at  the 
medio-tarsal  joint  deceive  you  into  attributing  it  to  the 
ankle  joint,  so  grasp  the  foot  that  the  os  calcis  moves 
synchronously  with  the  metatarsals.  Care  must  also  be 
taken  that  the  foot  is  moved  in  the  vertical  plane  of  the 
leg,  otherwise  abduction  in  dorsal  flexion  will  exaggerate 
the  true  angle  of  flexion.  The  range  of  active  move- 
ments of  all  the  joints,  with  the  foot  in  the  resting  posi- 
tion, should  be  determined.  Osgood  tests  the  muscles  in 
the  performance  of  the  various  movements;  and,  after 
determining  their  relative  strength,  prescribes  exercises, 
if  their  need  is  indicated,  to  restore  the  normal  muscular 
balance. 

Pain. —  Though  pain  is  of  no  more  importance  in 
making  a  diagnosis  of  an  abnormal  or  diseased  foot  than 


EXAMINATION  63 

it  is  in  morbid  conditions  elsewhere  in  the  body,  it  is 
often  of  great  significance  in  making  a  differential  diag- 
nosis, and  the  painful  spots  should  always  be  definitely 
located.  Pain  caused  by  pressure  over  a  diseased  or 
injured  bone  is  usually  more  circumscribed  and  elicited 
more  easily  and  definitely  than  the  pain  from  pressure 
on  a  strained  or  ruptured  muscle  or  ligament.  A  strained 
or  ruptured  muscle  or  ligament  is  always  painful  if 
stretched.  This  stretching  is  produced  in  the  ligament 
only  by  separating  the  ends,  but  in  a  muscle  a  contraction 
will  produce  it. 

Definite  pain  upon  pressure  over  the  body  of  the  os 
calcis  or  of  the  first  metatarsal  is  generally  due  to  disease 
or  injury  to  those  bones.  Pronounced  pain  over  the 
peroneal  tubercle  on  the  external  surface  of  the  os  calcis, 
is  due,  according  to  Goldthwait,  to  a  tension  of  the  syn- 
ovial sheath  of  the  peroneal  tendon  dragging  it  away 
from  its  attachments  to  this  tubercle. 

Pain  about  the  external  malleolus  in  cases  of  everted 
feet,  is  due  to  a  crowding  of  the  tissues  against  the  ex- 
ternal malleolus  from  malposition  of  the  tarsus,  accord- 
ing to  Golding-Bird.  The  pain  about  the  inner  side  of 
the  medio-tarsal  joint  may  be  due  to  an  inflammatory 
condition  of  this  joint,  or  to  strain. 


CHAPTER  IV 

SHAFFER'S    FOOT    (NON-DEFORMING    CLUB- 
FOOT).    WEAK-FOOT.     FLAT-FOOT 

The  condition  of  a  shortened  heel-cord  has  been  noted 
by  several  writers  and  more  or  less  importance  has  been 
attached  to  it.  Thus  Adams,  "  Club-Foot  "  :  "A  cer- 
tain amount  of  lameness  accompanied  by  inability  to 
walk  even  a  moderate  distance  without  fatigue,  follows 
this  condition  of  right-angled  contraction  of  the  tendo 
Achillis  and  in  consequence  of  the  limited  flexion  of  the 
ankle  joint  the  stride  is  necessarily  shortened;  for  the 
same  reason,  also,  the  feet  in  the  act  of  progression  are 
turned  outward  with  a  twisting  movement.  It  is  diffi- 
cult to  recognize  the  condition  from  the  absence  of  de- 
formity." 

And  thus  Holmes  Coote,  "  On  Joint  Diseases  "  :  "  In 
many  cases  of  talipes  valgus  the  tendo  Achillis  is  so  tight 
that  the  foot  can  not  be  raised  beyond  a  right  angle  to 
the  leg.  In  such  cases  a  cure  can  not  be  effected  without 
the  operation  of  tenotomy."  Tubby,  in  his  recent  work 
devotes  five  pages  to  "  This  simple  and  seldom  described 
condition  of  contraction."  Shaffer,  however,  was  the 
first  to  describe  its  mechanics,  or  rather  its  interference 
with  the  normal  mechanism,  its  clinical  signs  and  symp- 
toms, its  complications,  and  its  treatment,  for  which  he 

64 


SHAFFER  S    FOOT 


65 


invented  an  ingenious  apparatus  which  has  been  in  suc- 
cessful use  for  over  a  quarter  of  a  century. 

SHAFFER''S    FOOT 

The  chief  characteristic  of  this  condition  is  a  short- 
ening  of   the  gastrocnemius   and    of    the    soleus.     This 


Figs.  12-14.    Effect  of  a  Shortened  Gastrocnemius 

Fig.  12  is  a  schematic  drawing  representing  the  thigh,  leg  and 
foot,  with  the  knee,  ankle  and  medio-tarsal  joints  and  the  gastroc- 
nemius and  anterior  muscles  and  the  plantar  fascia. 

Fig.  13  shows  the  normal  lengthening  of  the  gastrocnemius  when 
the  anterior  tibial  muscles  contract,  flexing  the  leg  upon  the  foot. 
The  length  of  the  gastrocnemius  when  the  foot  is  at  a  right  angle, 
A,  has  been  increased  to  B. 

Fig.  14  illustrates  how,  by  bending  the  knee,  flexion  of  the  leg 
may  take  place  without  lengthening  of  the  gastrocnemius. 

shortening  is  not  enough  tO'  produce  the  deformity  of 
equinus  but  Hmits  dorsal  flexion.  Normally,  the  foot 
can  be  brought  tip  in  the  line  of  the  leg,  until  the  plan- 
tar   surface    forms    an    angle    with    the    leg    of    75 


66  DISEASES    AND   DEFORMITIES    OF    THE    FOOT 

degrees.  In  this  condition,  however,  this  angle  is  90 
or  100  degrees.  As  a  result,  when  the  foot  is  flat  on 
the  ground  and  the  tibia  is  being  flexed  on  the  foot,  the 
action  is  blocked  at  the  ankle  before  the  movement  is 
completed.  What  takes  place  may  be  readily  understood 
by  reference  to  the  diagrams.  Fig.  12  represents  the 
normal  position  of  the  leg  and  foot,  showing  the  anterior 
and  posterior  muscles  and  the  plantar  fascia.  Fig.  13 
illustrates  their  positions  as  the  body  is  brought  forward 
and  before  the  heel  is  raised  to  propel  the  body  forward 
upon  the  other  foot.  The  anterior  muscles  are  contract- 
ing and  flexing  the  leg  on  the  ankle.  The  posterior 
muscles  are  relaxed. 

Fig.  14  illustrates  what  may  take  place  if  the  posterior 
muscles  are  contracted  and  prevent  flexion  at  the  ankle: 
the  bending  of  the  knee  brings  the  heads  of  the  gas- 
trocnemius nearer  to  its  insertion,  thus  providing  for  the 
increased  ankle  movement. 

Fig  15  illustrates  how,  if  the  heel  is  raised,  this  ankle 
movement  may  be  increased ;  the  blocked  movement  being 
compensated,  without  bending  the  knee. 

Fig  16  shows  where  the  strain  will  be  felt  if  the  knee 
is  not  bent  and  the  heel  is  not  raised  and  the  anterior 
muscles  are  strongly  contracted  in  an  endeavor  to  flex 
the  tibia.  The  gastrocnemius  will  be  stretched,  and 
strain  will  be  felt  at  the  medio-tarsal  joint,  in  an  endeavor 
to  over-extend  it,  and  there  will  be  strain  of  the  plantar 
tissues,  which  prevent,  by  their  bow-string  action,  abnor- 
mal extension  of  this  joint.     The  dotted  line  shows  the 


SHAFFER  S    FOOT 


67 


normal  position  of  this  joint.  This  strain  will  be  due 
not  only  to  the  contraction  of  the  anterior  muscles  but 
also  to  the  weight  of  the  body  in  an  inverse  proportion 
to   the    amount   of   contraction   of    the   gastrocnemius. 


Figs.    15-16.    Effect  of  a    Shortened  Gastrocnemius 
Fig.   15.    In  this  figure  the  knee  is  not  flexed  and  the  gastroc- 
nemius is  not  lengthened,  but  by  raising  the  heel  the  leg  is  brought 
forward  to  form  an  angle  of  75  degrees  with  the  ground. 

Fig.  16  demonstrates  the  force  brought  to  bear  toward  extension 
of  the  medio-tarsal  joint  when  the  gastrocnemius  allows  of  slight 
dorsal  flexion,  to  85  degrees  in  this  figure,  and  the  consequent  strain 
on  the  plantar  tissues  with  lowering  of  the  dome  and  lengthening  of 
the  foot. 


Thus,  if  the  shortened  gastrocnemius  permits  of  the 
tibia's  being  flexed  10  degrees  beyond  the  vertical,  the 
weight  of  the  body,  acting  not  so  much  as  superimposed 
weight  as  power  to  a  long  lever  arm,  will  strain  the 
medio-tarsal  joint  and  the  plantar  tissues  much  more 


68  DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

than  if  the  flexion  of  the  tibia  is  nil,  is  stopped  at  a  right 
angle. 

Consequences. —  Therefore  the  consequences  of 
this  condition  will  depend  on  the  extent  of  the  contraction 
and  upon  the  use  to  which  the  abnormal  mechanism  is 
put.  With  flexion  limited  to  a  right-angle,  accommo- 
dation may  be  made  by  bending  the  knee  or  by  raising 
the  heel  during  attempted  flexion  of  the  leg,  and  by  taking 
short  steps.  Usually  patients  who  complain  that  they 
can  not  take  long  steps  or  can  not  wear  low-heeled  shoes 
will  be  found  to  have  this  limitation  of  motion  at  the 
ankle.  In  these  instances,  a  slight  cavus,  a  high  arch, 
will  usually  be  present  and  the  foot  will  be  shorter  than 
normal  from  a  slight  contraction  of  the  plantar  fascia. 

S5niiptoms. —  In  adults  the  complaint  for  which 
relief  is  sought  when  dorsal  flexion  is  limited  to  lOO  or 
90  degrees,  is  pain  in  the  calves,  about  the  knees,  often 
in  front  of  the  knee,  or,  more  rarely,  up  the  thighs,  some- 
times extending  to  the  buttocks  and  the  lumbar  region. 
This  pain  is  entirely  relieved  by  rest  and  brought  on  by 
walking.  It  is  due  to  muscular,  especially  gastrocnemic, 
strain.  It  may  be  so  severe  as  to  prevent  walking  more 
than  a  few  steps  without  rest.  Any  exercise  which  de- 
mands dorsal  flexion  will  be  found  to  be  difficult  or  im- 
possible: walking  down  stairs  will  sometimes  be  done 
backward,  as  the  necessity  of  flexing  the  leg  on  the  foot 
in  descending  is  impossible  for  these  patients  without 
bending  the  knee  or  raising  the  heel,  and  in  so  doing 
there  is  a  tendency  to  pitch  one  head  foremost  down  the 


SHAFFER  S    FOOT 


69 


rest  o£  the  flight.  There  may  be  a  history  of  frequent 
sprains  of  the  ankle  due  to  the  instabihty  of  the  joint. 
In  a  patient  whom  I  saw  in  consultation  there  was  com- 


FiGS.  17-18.  Illustrating  the  Difficulty  in  Descending  Stairs 
WHEN  Dorsal-Flexion  of  the  Foot  is  Limited 

Fig.  17.  The  right  leg  cannot  be  flexed  on  the  foot  so  as  to  per- 
mit the  left  foot  to  reach  the  next  step. 

Fig.  18.  This  difficulty  might  be  overcome  by  flexing  the  knee,  but 
this  would  be  most  awkward. 


plaint  of  a  feeling-  of  weakness  of  the  knees,  as  though, 
when  standing  he  felt  some  force  pressing  them  forward, 
trying  to  flex  them.  There  was  no  particular  pain. 
Examination  failed  to  reveal  anything  abnormal  with  the 


70 


DISEASES    AND    DEFORMITIES    OF    THE    FOOT 


knees  or  feet  except  a  limitation  of  dorsal  flexion  to  about 
90  degrees.  In  this  case  the  strain  of  the  short-gastroc- 
nemius  was  felt  in  its  tendency  to  flex  the  knee,  and  not 
at  all  in  the  ankle  or  foot. 


Figs,  19-20.  Illustrating  the  Difficulty  in  Descending  Stairs 
WHEN  Dorsal-Flexion  of  the  Foot  is  Limited 

Fig.  19.  By  raising  the  heel  the  shortening  of  the  muscle  may  be 
compensated,  but  this  endangers  one  to  a  pitch  head  foremost  down 
the  rest  of  the  flight. 

Fig.  20  shows  how  the  obstacle  of  this  limited  motion  is  frequently 
surmounted:  descent  is  made  backward,  dorsal-flexion  then  being 
unnecessary. 

In  children,  consultation  is  sought  on  account  of  the 
awkward  gait  and  the  clumsiness.  The  child  is  con- 
stantly stumbling  and  falling. 

On  the  other  hand,  with  a  contraction  less  marked 


SHAFFER  S    FOOT  7 1 

wherein  the  tibia  can  flex  on  the  foot  to  lO  degrees  or  so 
beyond  the  vertical,  the  added  weight  of  the  body  to  the 
strain  upon  the  medio-tarsal  joint  and  upon  the  entire 
dome  of  the  foot,  is  much  more  serious  in  its  deform- 
ing effects.  The  contraction  itself  is  not  so  incapaci- 
tating as  where  the  contraction  is  greater;  the  stride  is 
not  so  limited  and  the  muscle-strain  is  not  so  great. 
Pain  may  be  felt  only  after  unusual  exertion  and  is  more 
likely  to  be  limited  in  extent,  and  is  more  of  a  tired 
feeling  than  of  acute  suffering.  But  strain  toward  in- 
creased dorsal  flexion  at  the  medio-tarsal  joint  is  much 
more  pronounced  than  when  the  ankle  flexion  is  more 
limited,  and  the  plantar  tissues  are  now  the  subject  of 
severe  strain  at  each  step.  In  an  unconscious  attempt 
to  relieve  this,  the  foot  is  abducted,  as  by  so  doing  the 
limited  ankle  flexion  is  compensated  to  some  extent,  but 
this  vicious  attitude  hastens  the  oncoming  deformities. 

Thus  it  may  be  understood  how  this  condition  may 
cause  muscular  pain  from  stretching  of  the  calf  muscles, 
or  pain  about  the  knee  from  the  strain  of  supporting  the 
body  with  the  knee  slightly  flexed,  or  pain  at  the  astrag- 
alo-scaphoid  articulation  from  strain  of  overextension, 
or  over  the  tuberosities  of  the  os  calcis  from  a  periostitis 
set  up  by  the  strain  on  the  plantar  fascia.  Also  one  can 
understand  why  the  toes  may  be  turned  decidedly  in- 
wards when  the  dorsal  flexion  is  so  limited  as  to  approach 
an  equinus  deformity;  and  why,  with  less  limitation,  the 
foot  is  everted  even  while  the  dome  is  as  yet  normal. 
The  loss  of  firm  support  at  the  end  of  each  step  accounts 


72  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

for  the  weak  ankle  and  frequent  sprains  which  occur 
in  some  cases.  Then,  if  the  condition  persists,  the  rea- 
son is  understood  for  the  formation  of  calluses  under 
the  five  metatarsal  heads,  the  flattening  of  the  anterior 
arch,  and  finally  the  condition  of  flat-foot. 

Etiology. —  The  etiology  of  Shaffer's  foot  must  be 
sought  for  in  anything  that  will  cause  slight  shortening 
of  the  gastrocnemius.  Anything  that  will  cause  a  pro- 
longed shortening  of  the  calf  muscles  must  lead  to  a 
more  or  less  permanent  condition:  such  as  prolonged 
illness  during  which  the  patient's  foot  has  not  been  sup- 
ported but  allowed  to  remain  in  the  foot-drop  attitude. 
Possibly  some  nervous  conditions  may  keep  the  posterior 
muscles  from  being  perfectly  stretched.  Tubby  assigns 
an  imperfect  recovery  of  the  anterior  muscles  from  an 
attack  of  anterior  poliomyelitis  as  a  cause.  It  frequently 
follows  attacks  of  rheumatism  and  of  sciatica. 

Treatment. —  Treatment  consists  in  lengthening 
the  gastrocnemius.  As  a  very  slight  lengthening  is  all 
that  is  necessary,  the  tendo  Achillis  being  attached  to  so 
short  a  lever  arm,  an  operation  is  scarcely  demanded. 

Traction  Shoes. —  Shaffer's  traction  shoe  is  a  most 
efficient  apparatus  to  accomplish  the  desired  end.  In 
some  apparatuses  devised  for  this  purpose,  notably, 
Scarpa's  shoe,  the  mechanics  of  the  foot  have  not  been 
correctly  met.  The  heel  has  been,  pulled  directly  forward 
and  account  has  not  been  taken  of  its  moving  about  the 
axis  of  the  ankle  joint,  and  therefore,  during  dorsal 
flexion,  moving  in  an  arc,  downward  and  forward.     In 


SHAFFER  S    FOOT 


73 


Shaffer's  traction  shoe,  after  the  appHcation  to  the  foot 
and  the  securing  of  the  astragalar  strap  across  the  instep, 
the  traction,  by  means  of  the  ratchet  upon  the  heel-strap, 
draws  the  heel  downward  as  well  as  forward.  Every 
ounce  of  force  is  exerted  in  the  best  mechanical  direction, 
and,  when  properly  used,  is  felt  only  in  the  tendo  Achil- 


FiG.  21.    Author's  Traction  Shoe 
Comprising  the  essentials  of  Shaffer's  Traction  Shoe  with  the  ad- 
dition of  the  arc-ratchet.    The  vertical  ratchet  is  seldom  used  and  is 
not  necessary. 

lis  and  its  muscles.  Ten  minutes  of  daily  application 
of  intermittent  traction  will,  except  in  the  most  resistant 
cases,  show  an  increase  in  the  range  of  dorsal  flexion  after 
eight  or  ten  treatments. 

The  writer's  traction  shoe  has  added  a  ratchet,  curved 
to  correspond  with  an  arc  drawn  from  the  axis  of  the 
ankle,  which  moves  the  foot  as  a  whole,  and  therefore 


74  DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

each  component  part,  upon  the  radii  from  this  axis  as  a 
center.  This  machine  is  secured  to  a  chair  or  stool 
upon  which  the  patient  sits.  After  the  shoe  is  properly 
adjusted,  all  the  force  desired  can  be  applied  to  the  con- 
tracted tissues. 

The  machine  consists  of  two  lateral  bars,  a  stand,  and 
a  foot-piece.  The  lateral  bars  A,  A,  are  joined  at  their 
distal  ends  in  a  U-shaped  piece.  Their  proximal  ends 
are  bent  so  as  to  pass  beneath  the  chair  where  they  are 
secured  by  a  draw-pin  passing  through  sockets  screwed 
to  the  bottom  of  the  chair-seat.  The  continuity  of  the 
lateral  bars  is  interrupted  just  below  the  calf -band  M, 
and  the  ends  overlapping,  are  held  by  thumb  screws. 
Thus  these  bars  may  be  shortened  or  lengthened  as  de- 
sired. The  stand  B,  B,  supports  the  machine.  The 
foot-piece  consists  of  a  foot-plate  C,  and  a  heel-cup  D. 
The  foot-plate  is  joined  to  the  heel-cup  by  the  ratchet- 
bar  G  passing  through  the  sheath  E,  which  is  secured 
to  the  bottom  of  the  heel-cup.  The  entire  foot-piece  is 
riveted  to  the  lateral  bars  at  j,  j,  and  by  means  of  the 
ratchet  F,  can  be  moved  about  the  axis  passing  through 
j,  j.  The  act  of  the  ratchet  F,  is  constructed  on  the 
radius  jF,  To  the  bottom  of  the  foot-plate  are  riveted 
two  buckles  h,  h,  which  secure  the  heel-strap.  This  strap 
passes  behind  the  heel,  forward  on  both  sides  of  the  foot, 
over  the  hangers  i,  i,  projecting  upward  from  the  front 
of  the  foot-plate,  and  backward  to  the  buckles.  On  each 
side  of  the  heel-cup  are  rowels,  k,  k,  through  which  the 
astragalar  strap,   S,  is  roved.     The  strap  crosses  over 


SHAFFER  S    FOOT 


75 


the  ankle,  opposite  the  head  of  the  astragalus,  is  doubled 
on  itself  and  buckled. 

The  method  of  application  is  as  follows :     The  patient 


Fig.  2'2.    Author's  Traction  Shoe 
Illustrating  in  detail  its  various  parts,  which  are  described  in  the 

text. 

is  seated  in  the  chair,  the  heel  placed  in  the  heel-cup,  D, 
and  the  lateral  bars  A,  A,  adjusted  by  means  of  the 
thumb  screws  to  the  exact  length  of  the  limb  with  the 


'jd  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

leg  fully  extended.  It  is  necessary  that  the  axis  of  the 
ankle-joint  pass  through  the  axis  of  the  foot-piece,  j,  j. 
The  heel-strap  makes  this  adjustment  possible.  While 
fitting  the  apparatus  the  foot-piece  should  be  plantar 
flexed  to  an  angle  affording  an  easy  position  for  the 
foot.  The  last  thing  to  be  done  is  to  fasten  the  strap 
of  the  calf -band,  thus  preventing  the  knee  from  flexing 
as  the  strain  comes  on  the  gastrocnemius.  Traction  may 
now  be  started.  Using  the  key,  f,  the  ratchet,  F,  is  made 
to  pass  forward  and  around  the  axis  j,  j.  Everything  on 
that  foot-piece  will  move  through  arcs  the  radii  of  which 
extend  from  the  common  center.  The  foot  is  thus 
moved  forcibly  about  the  ankle-joint.  When  tautness  of 
the  tendo  Achillis,  as  ascertained  by  palpation  and  by 
the  sensations  of  the  patient,  warns  one  that  the  limit  of 
flexion  is  reached,  the  astragalar  strap  is  applied  and 
a  momentary  hyperextension  produced  by  means  of  the 
antero-posterior  ratchet,  G.  This  is  the  part  which  is 
exactly  similar  to  Shaffer's  traction  shoe. 

After  one  or  two  treatments  with  either  of  these  appa- 
ratuses, the  patient  will  usually  express  himself  as  noticing 
an  improvement.  The  pain  and  discomfort  is  lessened, 
the  foot  feels  "  lighter "  and  walking  is  easier.  The 
patient  should  not  be  discharged  until  the  normal  extent 
of  dorsal  flexion  has  been  obtained  and  all  faulty  postures, 
in  walking  and  standing,  corrected. 

Operation. —  Tenotomy  of  the  tendo  Achillis  is 
done  by  some  surgeons  for  this  condition  but  is  not 
advocated  by  many.     Lengthening  of  the  tendon  by  open 


SHAFFER  S    FOOT 


17 


operation,  as  recommended  by  Tubby,  is  much  more 
exact  and  can  not  result  in  a  calcaneous  deformity,  which 
that  surgeon  beheves  to  be  a  danger  of  simple  tenotomy. 
By  the  open  method,  the  tendon  is  divided  half  way 


Fig.  23.    Lengthening  the  Tendo  Achillis 

After  making  the  two  incisions  which  extend  half  way  across  the 
tendon  from  opposite  sides  and  at  a  suitable  distance,  one  above 
the  other,  and  then  connecting  them  with  a  longitudinal,  central  in- 
cision, the  foot  is  placed  in  the  corrected  position  and  the  over- 
lapping parts  sutured. 

through  its  width,  by  two  incisions  from  opposite  sides, 
one  being  two  inches  or  more  above  the  other.  These 
two  partial  divisions  are  then  united  by  a  vertical  central 
incision  which  joins  their  innermost  ends  at  right  angles. 
The  foot  is  next  placed  in  its  proper  position  of  full 


78  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

dorsal  flexion,  the  divided  parts  of  the  tendon  sliding  on 
each  other  leaving  a  gap  at  each  transverse  incision  but 
no  gap  extending  clear  across  the  tendon,  and  it  is  then 
sutured.  The  foot  is  put  up  in  plaster-of-Paris  and 
should  be  retained  for  three  weeks  in  this  position,  either 
with  the  plaster  dressing  or  by  a  brace. 

Although  these  cases  present  no  deformities  of  the 
dome  of  the  foot,  many  are  treated,  through  faulty  diag- 
nosis, as  though  they  were  weak-  or  flat-foot,  with 
strapping,  wedge  soles,  exercises  and  so  forth,  and  even 
with  braces,  and  are  sometimes  cured  by  these  means 
through  the  correction  of  attitudes  which  aggravate  the 
condition  and  through  forcing  an  active  stretching  of 
the  gastrocnemius, 

WEAK-FOOT 

Two  Classes. —  Weak-foot  we  would  divide  into 
two  classes :  the  ligamentous  and  the  muscular.  They 
may  exist  together  but,  at  least  in  the  early  stages,  the 
weakness  may  be  predominantly  either  ligamentous  or 
muscular.  The  chief  reason  for  making  the  differenti- 
ation, where  possible,  is  to  meet  the  specific  indications 
in  treatment  and  to  avoid  the  prescribing  of  unnecessary 
and  possibly  injurious  remedies. 

Characteristics. —  In  either  form  the  patient  stands 
and  walks  with  the  feet  abducted.  There  is  usually  a 
listing  of  the  foot  to  the  inner  side,  which  is  noticeable 
with  the  shoes  on  or  ofT.  The  soles  of  the  shoes  will 
show  more  wear  along  the  inner  side.     The  counter  on 


WEAK- FOOT  79 

the  inner  side  may  overrun  the  heel;  and  the  leather  be- 
tween the  heel  and  toe  of  the  shoe,  along  the  inner  side, 
may  be  drawn  into  furrows  or  wrinkles  lying  in  a  more 
or  less  longitudinal  direction.     These  conditions  come 


Figs.  24-25.    Adducted  and  Everted  Feet 
In  Fig.  24  note  bulging  along  the  inner  border  and  the  prominent 
internal   malleolus. 

In  Fig.  25  note  that  the  back  seam  of  the  shoe  is  directed  down- 
ward and  inward,  instead  of  straight  downward,  and  that  the 
inner  border  of  heels  are  more  worn  than  the  outer.  The  leather 
over  the  internal  malleoli  may  be  worn  or  may  be  dirty,  showing 
interference  as  the  feet  pass  one  another  in  walking. 

from  the  strain  on  this  part  of  the  shoe,  produced  by  the 
abduction  of  the  forefoot.  The  leather  over  the  inner 
ankles  may  be  worn  from  the  interference  due  to  walking 
with  the  forefoot  abducted. 

While  the  patient  is  standing  in  bare  feet,  the  earliest 
evidence  of  weak-foot  is  to  be  seen  in  the  altered  direc- 
tion of  the  tendo  Achillis.  Its  direction  will  be  down- 
ward and  outward  instead  of  directly  downward.  It 
should  be  borne  in  mind  that  this  sign  is  also  present 
when  there  is  a  shortened  heel-cord  without  any  marked 
weakness.  The  prominence  of  the  internal  malleolus 
will  also  be  increased.  If  there  is  much  abduction  of 
the  forefoot,  the  altered  direction  of  the  long  axis  of  the 
foot  will  give  the  appearance  of  the  external  malleolus 


8o 


DISEASES    AND    DEFORMITIES    OF    THE    FOOT 


being  advanced  to  a  position  more  nearly  in  line  with  the 
internal  malleolus.  In  marked  flat-foot  it  will  apparently 
be  even  in  advance  of  the  internal  malleolus.  In  neither 
case  has  any  actual  change  taken  place  in  the  relation  of 


Fig.  26,    Abducted  and  Everted  Feet 
Seen  from  behind.     Note  altered  direction  of  the  tendo  Achillis, 
valgus  of  the  ankle  and  the  spreading  out  of  the  heel. 


Fig.  27.    Abducted  and  Everted  Feet 
Seen  from  in  front. 

the  tibia  to  the  fibula.  The  amount  of  bulging  on  the 
inner  side  of  the  ankle  will  depend  upon  the  degree  of 
weakness  of  the  muscles  and  of  the  ligaments.  If  the 
former  are  mostly  at  fault,  the  deformity  will  be  little 


WEAK-FOOT 


8i 


or  not  at  all  changed  whether  the  patient  stands  or  walks. 
On  the  other  hand,  if  the  greater  weakness  lies  in  the 
ligaments,  the  deformity  will  be  obliterated  whenever  the 
muscles  are  brought  into'  play,  as  when  the  patient  walks 
or  stands  on  tip-toe. 

Pain  is  more  apt  to  be  present  and  to  be  more  severe 


Figs.  28-29.  Advancement  of  the  External  Malleolus 
Fig.  28  shows  the  normal  relative  position  of  the  external  to  the 
internal  malleolus.  If  the  fore-foot  is  abducted  as  shown  in  the 
dotted  lines  and  then  the  foot  as  a  whole  turned  inwards  by  totating 
the  leg,  as  has  been  done  in  Fig.  29,  the  external  malleolus  will  ap' 
parently  be  displaced  forward. 

in  the  muscular  form.  The  feet  tire  sooner  than  they 
should.  There  may  be  some  synovitis :  this  may  be  evi- 
dent in  front  of  the  external  malleolus,  over  the  sub- 
astragaloid  and  over  the  calcaneo-cuboid  joints,  and 
perhaps  less  frequently  on  the  inner  side  below  the  mal- 
leolus and  over  the  astragalo-scaphoid  joint. 


82  DISEASES   AND   DEFORMITIES    OF   THE    FOOT 

If  there  is  synovitis  of  the  ankle  joint,  bulging  will 
be  evident  between  the  tendons  on  the  front  of  the  ankle 
and  on  each  side  of  the  tendo  Achillis. 

Improper  use  of  the  foot  must  result  in  a  weakening 
of  its  muscles  and  ligaments  and,  as  improper  use  in  both 
standing  and  walking  is  more  common  than  proper  use, 
those  whose  occupation  demands  their  being  a  great  deal 
on  their  feet  are  the  greatest  sufferers.  Osgood  *  has 
made  a  study  of  the  comparative  strengths  of  the  ad- 
ductors and  abductors  of  the  foot  and  the  variations  in 
this  ratio  in  the  normal  and  in  "  foot-strain."  He  found 
the  ratio  of  the  adductor  pull  to  the  abductor  pull  in 
normal  feet  to  be  lo  to  8.2  in  favor  of  the  adductors. 
In  pronated  feet  without  symptoms  10  to  10.5  in  favor 
of  the  abductors.  In  pronated  feet  with  symptoms  10 
to  10.8  in  favor  of  the  abductors.  In  acute  feet  with 
valgus  10  to  12.2  in  favor  of  the  abductors. 

Weak-foot  is  common  in  children  who  have  grown 
rapidly  and  in  whom  the  muscular  development  has  not 
kept  pace  with  the  bony  growth.  This  inequality  of 
growth  is  made  more  evident  by  severe  sickness,  for  the 
bones  seem  to  take  all  the  nourishment  they  need  regard- 
less of  the  condition  of  the  other  parts  of  the  body. 

The  ligamentous  variety  of  weak-foot  is  frequently 
associated  with  rachitis.  The  musculature  may  or  may 
not  be  normal.  The  ligaments  of  other  joints  may  be 
lax;  it  may  be  possible  to  extend  the  elbow  beyond  its 
normal  limitation;  there  may  be  lateral  movement  of  the 

*  Boston  Medical  and  Surgical  Journal,  March  13,  1913. 


FLAT-FOOT  83 

knee  when  it  is  in  the  extended  position,  and  postural 
scoHosis  may  exist. 

Results  of  Non-treatment. —  If  weak-foot  is  per- 
mitted to  exist  without  protection,  the  unnatural  strain, 
due  to  the  abduction  and  eversion,  together  with  the  ab- 
sence of  normal  functionating,  increases  the  weakness. 
In  this  position  of  the  foot,  all  movements  at  the  medio- 
tarsal  joint  and  at  the  sub-astragaloid  become  very  pain- 
ful, and  to  avoid  this  muscular  spasm  develops,  first 
marked  in  the  peroneals,  in  an  effort  at  immobilization. 
Further  use,  without  treatment,  is  accompanied  by  in- 
creased muscular  spasm,  resulting  in  rigidity,  followed 
by  a  lowering  of  the  dome  of  the  foot,  by  bony  changes, 
and  by  flat-foot  as  a  final  result. 

Treatment. —  This  is  taken  up  with  the  treatment 
of  flat-foot. 

FLAT-FOOT 

The  diagnosis  of  flat-foot,  if  the  condition  of  weak- 
foot  is  recognized  as  an  entity,  rests  upon  the  fixed  re- 
duction or  obliteration  of  the  dome  of  the  foot.  Walsham 
recognizes  four  degrees  of  deformity;  oncoming,  pro- 
nounced, rigid,  and  osseous.  As  weak-foot,  according 
to  our  definition,  becomes  a  flat-foot  only  when  complete, 
voluntary  restoration  of  the  normal  relations  of  the 
bones  becomes  impossible,  and  as  this  restoration  in  the 
early  stages  is  prevented  only  by  spasm,  it  would  seem 
to  be  simpler  to  have  but  two  stages  of  flat-foot:  the 
spasmodic  and  the  osseous.     The  former  (as  it  is  always 


84  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

progressive  if  the  etiological  factors  persist)  could  be 
divided  into  the  oncoming,  which  is  more  or  less  easily 
corrected  by  manipulation ;  and  the  rigid,  where  nothing 
short  of  great  force,  necessitating  an  anesthetic,  will 
allow  of  restoration  of  the  dome,  but  where  no  marked 
bony  changes  have  as  yet  followed.  The  osseous  in- 
cludes all  cases  which  are  irreducible  without  removal  of 
bony  obstruction. 

Many  qualifying  and  descriptive  terms  may  be  used 
which  are  an  aid  in  history-taking  and  provide  a  more 
or  less  clear  description  of  the  case,  either  as  to  an  etio- 
logical factor  or  as  to  the  condition,  such  as  traumatic, 
paralytic,  inflammatory,  painful,  etc.,  but  it  is  unnecessary 
to  classify  under  any  such  extended  system. 

Osseous  Fiat-Foot. —  This  is  the  result  of  unre- 
lieved eversion  and  abduction  and  may  or  may  not  be  a 
painful  condition.  If  firmly  established  with  practically 
no  movement  in  the  intra-tarsal  joints,  the  pain  associ- 
ated with  it  will  arise  from  uneven  plantar  pressure. 
All  the  finer  accommodating  movements  being  lost,  the 
bones  can  not  be  shifted  to  accommodate  themselves  to 
alterations  in  the  plane  of  the  body  containing  the  center 
of  gravity,  nor  to  changes  in  the  surfaces  upon  which 
the  foot  rests,  and  calluses  will  form  at  the  spots  receiv- 
ing the  greatest  weight,  the  pain  depending  to  a  great 
extent  on  the  condition  of  these  calluses.  This  foot,  the 
veritable  flat-foot,  has  lost  all  the  functions  of  a  normal 
foot  except  that  of  support,  and  the  supporting  is  done 
in  an  inanimate  rather  than  in  a  physiological  way.     Yet 


FLAT-FOOT  85 

the  possessor  of  such  a  foot  may  have  so  accommodated 
himself  to  the  condition  as  to  be  unaware  of  the  extent 
of  his  deformity.  Many  cases  of  the  most  marked  type 
exist,  in  which  pain  was  never  severe. 

Pathology. —  In  these  conditions  of  the  foot  the 
pathology  is  limited  to  stretching  of  some  muscles  and 
ligaments  and  to  contracting  of  others,  except  in  that  of 
osseous  flat-foot.  Here  there  are  certain  bony  changes 
which  should  be  recognized  in  planning  treatment.  The 
eversion,  the  rotation  on  the  sub-astragaloid  axis,  has  so 
altered  the  position  of  the  os  calcis  that  its  external 
inferior  tubercle  is  lifted  from  the  supporting  surface 
and  an  articulation  may  be  formed  between  the  external 
surface  of  the  bone  and  the  external  malleolus.  The 
anterior  part  of  the  os  calcis  has  been  abducted.  The  ex- 
ternal arch,  with  the  entire  dome,  has  been  lowered  and 
the  eversion  has  so  rotated  the  bones  that  the  cuboid  is 
on  about  the  same  horizontal  plane  as  the  upper  part  of 
the  head  of  the  astragalus.  The  superior  faces  of  the 
internal  cuneiform  and  of  the  first  metatarsal  and  the 
upper  part  of  the  head  of  the  astragalus,  look  inward. 
It  is  this  rotation  of  the  foot  which  throws  the  external 
malleolus  into  such  prominence  and  which  makes  the  in- 
ternal malleolus  less  so.  It  is  the  abduction  of  the  fore- 
foot which  gives  the  appearance  of  the  external  malleolus 
having  been  moved  to  a  position  in  advance  of  its  normal 
one.  The  scaphoid  may  be  greatly  altered  in  shape 
(Walsham.  Lorenz)  and  its  tuberosity  look  down- 
ward instead  of  inward,  thus  giving  an  altered  direction 


86  DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

to  the  tibialis  posticus.  The  greater  part  of  the  inner 
surface  of  the  head  of  the  astragalus  is  uncovered  as  it 
is  depressed  and  rotated  inward  while  the  scaphoid,  in 
relation  to  it,  is  displaced  upward  and  outward.  Exuber- 
ant bone  may  be  present  on  what  is  now  the  outer  and 
upper  part  of  the  head  of  the  astragalus  and  also  about 
the  cuboidal  facet  of  the  os  calcis. 

TREATMENT    OF    WEAK-FOOT    AND    FLAT-FOOT 

Our  object  is  reduction  of  deformities,  whether  easily 
reducible  or  fixed,  and  the  restoration  of  normal  func- 
tions. Usually  these  two  processes,  reducing  deformity 
and  restoring  function,  can  go  on  together,  but  under  no 
circumstances  should  a  cure  be  pronounced  until  both 
results  are  obtained. 

Weak-Foot. — If  a  weak-foot  exists,  wherein  the  foot 
at  rest  appears  about  normal  but  upon  weight-bearing 
assumes  an  abducted  and  flattened  appearance,  with  more 
or  less  valgus,  means  must  be  taken  to  preserve  the  nor- 
mal position  of  the  foot  while  it  is  in  use  and  steps  taken 
at  the  same  time  to  restore  strength  to  the  weakened 
muscles  and  ligaments. 

Mild  Cases. —  Especially  in  cases  of  the  liga- 
mentous variety,  nothing  may  be  needed  to  hold  the  foot 
in  the  corrected  position  beyond  the  shaping  of  the  heels 
and  soles  of  the  shoes  in  such  a  way  that  the  foot  is  held 
inverted  when  weight-bearing,  as  inversion  alone  may 
correct  the  abduction.  This  is  done  by  having  the  heel 
and  sole  made  wedge-shaped,  with  the  thickest  part  of 


WEAK-FOOT    AND    FLAT-FOOT 


87 


the  wedge  on  the  inner  side  of  the  foot  and  the  edge 
of  the  wedge  on  the  outer  side.  The  amount  of  thick- 
ness of  the  heel  and  sole  along  the  inner  side  will  be 
found  to  vary  in  different  cases,  but  the  correct  amount 
can  be  determined  by  examining  the  feet  from  behind 
when  a  wedge  is  inserted  under  the  foot.  In  mild  cases 
an  eighth  of  an  inch  is  all  that  is  required,  but  more  fre- 


FiGS.  30-31.  A  Shoe  Before  and  After  the  Insertion  of  Wedges 
Wedges  are  placed  at  the  anterior  and  inner  part  of  the  heel  and 
at  the  posterior  and  inner  part  of  the  sole  for  the  purpose  of  cor- 
recting faulty  balance.  Figs.  30  and  31  show  a  shoe  before  and 
after  the  insertion  of  these  wedges. 

quently  a  quarter  or  even  half  of  an  inch  will  be  needed. 
The  ideal  way  of  making  the  wedge  is  to  construct  it 
so  that  the  sole  and  heel  will  correspond  to  segments  of 
the  dome  formed  when  the  two  feet  are  placed  together. 
That  is,  the  wedge  added  to  the  heel  will  be  highest  at  the 
internal  corner  and  slope  downward  toward  both  the 
external  border  and  the  back;  and  the  wedge  added  to 
the  sole  will  be  the  highest  at  the  internal  and  back  part 


88 


DISEASES    AND   DEFORMITIES    OF   THE    FOOT 


and  from  there  slope  downward  both  externally  and  for- 
ward. 

The  Beely-heel  extends  inward  to  a  marked  degree  — 
and  thus  offers  an  irresistible  obstacle  to  eversion  —  when 
the  most  marked  deformity  is  in  the  sub-astragaloid  joint, 
this  inward  extension  of  the  heel  should  be  prescribed. 


Figs.  32-33.    Inverting  Heel 
The  extension  of  the  heel  inwards  prevents  eversion  of  the  foot. 
This  illustration  is  after  Beely,  taken  from  Handbuch  der  Ortho- 
padischen  Chirurgie.    The  toe  of  the  shoe  is  not  to  be  recommended. 


By  extending  the  heel  forward  so  that  it  gives  secure 
support  as  far  forward  as  the  astragalo-scaphoid  joint 
the  adduction  may  be  more  securely  held.  This  may  be 
done  by  the  Thomas  heel  which  extends  forward  three- 
quarters  of  an  inch  farther  on  the  inner  than  on  the 
outer  half.  Adhesive  plaster  strapping,  such  as  is  de- 
scribed for  the  spasmodic  condition,  may  be  applied  until 


WEAK-FOOT    AND    FLAT-FOOT  89 

the  patient  becomes  accustomed  to  the  new  position; 
until  the  muscular  sense  has  become  re-educated. 

Exercises. —  The  object  of  these  is  to  strengthen 
the  muscles  and  ligaments.  There  are  many  athletic 
sports  which  will  do  all  the  exercising  necessary,  at  least 
in  the  mild  cases,  and  for  young  people  they  will  be  found 
to  be  a  much  more  welcome  prescription  than  definite 
foot-exercises  to  be  carried  out  in  the  bed-chamber.  As 
such  may  be  mentioned,  tennis,  running,  jumping,  cycling, 
ball,  and  in  fact  any  game  which  necessitates  one's  spring- 
ing about  on  the  toes.  Roller-skating  is  injurious  because 
the  feet  are  abducted.  Dancing  is  very  beneficial  for 
weak- foot. 

Specific  exercises  will,  however,  frequently  have  to 
be  ordered.  There  are  three  sets  which  will  be  very 
useful  in  most  cases:  with  the  feet  forming  a  square, 
slowly  raising  one's  self  up  on  the  toes  and  slowly  re- 
turning to  the  heels;  walking  about  the  room  on  the 
outer  borders  of  the  feet ;  using  the  toes  to  pick  up  arti- 
cles and  also  strongly  separating  the  toes.  In  the  first 
exercise,  care  should  be  taken  that  the  feet  are  in  the 
proper  position,  parallel  and  forming  the  two  sides  of  a 
square.  The. exercise  must  be  done  very  slowly  so  that 
.  no  help  is  given  to  the  muscles  by  a  swinging  motion  of 
the  body  or  by  allowing  gravity  to. return  the  heels 
quickly  to  the  ground.  It  will  be  found  to  be  a  great 
help  in  obtaining  a  cure  if  the  patient  is  taught  the  habit 
of  rising  on  the  toes  while  the  shoes  are  on.  This  will 
not  take  the  place  of  the  exercise  as  done  bare- footed,  but 


9b 


DISEASES    AND   DEFORMITIES    OF   THE    FOOT 


if  the  patient  is  instructed  never  to  stand  for  more  than  a 
minute  or  two  without  rising  on  tip-toe  and  once  in  a 


Fig.   34.    An   Exercise  for  Weak-Feet 
Walking  about  the  bedroom  on  the  outer  borders  of  the  feet  tends 
to  overcome  abduction  and  eversion  and  strengthens  the  muscles  of 
adduction    and    of    inversion.    This    exercise    is    recommended    by 
Gibney. 

while  to  rest  on  the  outer  border  of  the  shoes,  it  will 
give  a  valuable  rest  to  the  ligaments.     A  most  valuable 


WEAK-FOOT    AND    FLAT-FOOT 


91 


exercise,  which  can  not  be  done,  though,  without  assist- 
ance, is  rotation  of  the  forefoot.  The  patient  is  seated 
with  the  leg  resting  on  the  physician's  knee.  The  phy- 
sician holds  the  heel  securely  in  one  hand,  pointing  the 
index  finger  of  the  other  hand  downward,  with  its  tip 
just  in  front  of,  dorsal  to,  the  second  toe;  the  patient 


Fig.  35.    The  Feet  at  Rest 
When  sitting,  the  legs  should  be  crossed  and  the  feet  allowed  to 
rest  on  their  external  borders.    This  position  puts  all  the  structures 
at  rest. 


moves  the  forefoot,  first  in  adduction  and  then  through 
flexion,  abduction  and  extension,  in  such  a  way  as  to  carry 
the  forefoot  in  circumduction  around  the  physician's  fin- 
ger, which  is  held  steadily  in  the  one  position.  The 
exercises  for  the  toes  are  directed  toward  increasing  the 


92  DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

strength  of  the  smaller  muscles  and  thereby  strengthening 
the  anterior  arch,  which  will  generally  be  weakened  with 
the  rest  of  the  dome.  When  sitting,  patients  with  a 
tendency  to  abduction  and  eversion  should  cross  their 
legs  in  such  a  way  that  the  feet  will  rest  upon  their  ex- 
ternal borders.  This  will  rest  all  the  foot-structures 
and  be  of  inestimable  value  in  preventing  deformities. 

These  exercises  will,  of  course,  be  impossible  unless 
the  foot  is  flexible. 

Arch  Supporters. — There  is  always  associated  in 
the  minds  of  both  the  laity  and  the  profession,  in  con- 
nection with  the  treatment  of  all  these  foot-troubles,  the 
question  of  arch  supporters.  Few  patients  (complaining 
of  their  feet),  come  to  the  orthopedic  surgeon,  who  have 
not  worn  at  least  one  variety  of  the  many  to  be  found 
on  the  market.  And,  although  the  practice  of  unpro- 
fessional prescribing  of  arch  supporters  should  be  unre- 
servedly condemned,  for  much  the  same  reason  as  is 
counter-prescribing  of  drugs,  I  should  not  be  surprised 
if  shoemakers  and  salesmen  of  these  articles  had  cured 
as  many  painful  feet  as  have  physicians.  If  this  is  true 
it  is  not  because  of  any  superior  intelligence  on  the  part 
of  the  cobbler  or  clerk,  but  because  so  few  physicians 
possess  any  better  knowledge  of  the  etiology  and  pathol- 
ogy of  these  conditions  than  do  the  knights  of  the  last, 
and  the  latter  have  a  much  greater  opportunity  to  have  a 
*'try"  at  treatment;  and  that,  too,  usually  before  the 
condition  has  become  what  the  patient  would  call  serious. 

It  is  a  fact  that  many  physicians,  and  not  a  few  of 


WEAK-FOOT    AND    FLAT-FOOT  93 

them  surgeons,  are  to-day  sending  their  patients  who 
complain  of  painful  feet  to  the  brace-maker  or  the  shoe- 
maker with  orders  for  arch  supporters.  The  object 
sought  by  all  these  people  concerned  is  to  supply  some- 
thing that  will  directly  support  the  longitudinal  arch, 
which  often  feels  weak  and  may  have  the  appearance  of 
being  depressed.  This  object  is  never  obtained,  but  the 
relief  of  symptoms  and  even  a  cure  may  nevertheless 
result.  If  something,  anything,  is  placed  in  the  shoe  in 
the  neighborhood  of  the  astragalo-scaphoid  joint,  which 
will  force  the  patient  instinctively  to  adduct  the  forefoot 
so  as  to  avoid  pressure  against  that  object,  it  may  lead 
to  a  cure.  Adduction  of  the  forefoot,  by  causing  a 
concavity  of  the  otherwise  straight,  or  even  convex,  inner 
border,  makes  room  for  the  foreign  body,  the  supporter, 
and  relieves  pressure  from  it;  and  this  adduction,  the 
strong  position  of  the  foot,  relieves  the  strain  which  is 
causing  the  pain  and  weakness.  Likewise  certain  cases 
may  be  cured  by  having  a  supporter  so  shaped  as  to  act 
like  an  incline-plane,  causing  an  inversion  of  the  foot; 
and  if  the  forward  part  inclines  downward,  forward,  and 
outward  it  may  help  to  produce  adduction  as  well.  When 
these  supporters,  braces,  or  plates,  as  they  are  variously 
called,  have  any  curative  effect  it  must  be  their  helping 
directly  by  force  or  indirectly  by  exciting  muscular  action, 
in  keeping  the  foot  adducted  and  inverted.  They  can 
be  of  no  use  and  will  cause  greater  pain  if  the  foot  is  not 
perfectly  flexible;  and  if  the  foot  is  flexible  they  usually 
do  no  more  than  postpone  the  time  when  expert  treat- 


94  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

merit  will  become  necessary,  unless  accidentally  something 
is  done  to  strengthen  the  weakened  muscles  and  ligaments 
while  the  supporter  is  being  worn.  Of  themselves  they 
tend  to  injure  the  foot  by  limiting  its  intrinsic  move- 
ments and  therefore  weakening  its  structures.  If  at  the 
beginning  of  foot-trouble,  a  correct  diagnosis  were  made 
and  proper  remedial  measures  taken,  there  would  be  com- 
paratively few  cases  which  would  need  any  brace  of  any 
description. 

When  for  any  reason  the  patient  can  not  be  taught  to 
stand  and  walk  properly, —  and  there  are  many  such,  espe- 
cially among  charity  patients, —  a  correctly  constructed 
brace  may  be  applied  and  worn  with  great  profit  for 
some  months. 

Whitman's  Brace. — This  is  designed  not  as  a  re- 
tentive apparatus  alone  but  as  a  corrective  one  also.  It 
is  supposed  to  reeducate  the  muscles  of  the  foot.  When 
one  stops  to  consider  what  a  revolution  it  is,  in  the  use 
of  all  the  structures  of  the  foot,  to  change  from  the  ab- 
ducted, everted  position  to  that  of  adduction  and  inversion 
it  is  easy  to  appreciate  that  care  and  attention  and  intelli- 
gence as  well  are  necessary,  and  many  have  not  these  to 
give  even  in  forwarding  their  own  cure.  With  a  Whit- 
man's brace  it  is  impossible  for  the  foot  to  assume  the 
vicious  attitude.  The  brace  serves  as  a  teacher  at  each 
step,  but  the  pupil  will  find  the  teacher  too  severe,  if  any 
spasm  exists :  if  the  foot  is  not  perfectly  flexible  and  the 
brace  a  perfect  fit. 

To  make  this  brace,  a  cast  of  the  foot  must  be  taken 


WEAK-FOOT    AND    FLAT-FOOT  9j 

with  the  foot  in  the  correct  position.  If  made  over  a 
cast  of  the  abducted,  prone  foot  it  cannot  be  efficient. 
Whitman's  directions  are :  "  Seat  the  patient  in  a  chair, 
in  front  of  him  place  another  chair  of  equal  height;  on 
it  lay  a  thick  pad  of  cotton-batting  and  cover  it  with  a 
square  of  cotton  cloth.  Put  about  a  quart  of  cold  water 
in  a  basin  and  sprinkle  plaster-of-Paris  on  the  surface 
until  it  does  not  readily  sink  to  the  bottom,  then  stir. 
When  the  mixture  is  of  the  consistency  of  very  thick 
cream,  pour  it  upon  the  cloth.  The  patient's  knee  is  then 
flexed  and  the  outer  side  of  the  foot,  previously  smeared 
lightly  with  vaseline,  is  allowed  to  sink  into  the  plaster 
and,  the  borders  of  the  cloth  being  raised,  the  plaster  is 
pressed  against  the  foot  until  rather  more  than  half  is 
covered.  The  foot  should  be  at  a  right  angle  to  the 
leg  and  the  whole  should  be  in  the  plane  perpendicular 
to  the  seat  of  the  chair.  As  soon  as  the  plaster  is  hard 
its  upper  surface  is  coated  with  vaseline  and  the  remainder 
of  the  foot  is  covered  with  plaster;  the  two  halves  are 
then  removed,  smeared  lightly  with  vaseline,  and  ban- 
daged together.  The  interior  is  dampened  with  soap 
suds  and  it  is  then  filled  with  plaster  cream.  In  most 
instances  it  will  be  of  advantage  to  deepen,  in  the  plaster 
model,  the  inner  and  the  outer  segments  of  the  arch,  in 
order  that  the  arch  of  the  brace  may  be  slightly  exag- 
gerated, especially  at  the  heel,  so  that  the  depression  of  the 
anterior  extremity  of  the  os  calcis  may  be  prevented. 
Upon  the  model  the  outlines  of  the  brace  are  drawn." 
The  brace  consists  of  a  sole  and  two  flanges.     The  sole 


96  DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

part  extends  from  the  center  of  the  heel  to  the  ball  of  the 
great  toe.  While  the  posterior  border  lies  squarely 
across  the  heel  the  anterior  border  curves  backward  and 
outward  from  the  junction  of  the  middle  and  internal 
thirds  of  the  plantar  surface  at  the  ball  of  the  great  toe 
to  the  anterior  edge  of  the  external  flange.  The  internal 
flange  is  broad  rising  sufficiently  high  to  cover  the  as- 
tragalo-scaphoid  articulation  and  extending  from  the 
posterior  to  the  anterior  edge  of  the  sole  plate.  The 
external  flange,  much  smaller  than  the  internal,  covers 
the  calcaneo-cuboid  articulation. 

Shaffer's  Brace. — Shaffer's  method  of  applying 
braces  is  to  have  a  piece  of  steel  cut  to  fit  the  shoe,  which 
must  itself  be  a  proper  fit,  with  a  flange  extending  up 
over  the  inner  side  of  the  medio-tarsal  joint.  This  flange 
is  shaped  over  molds  provided  for  that  purpose  and  of 
several  sizes,  designated  by  their  relative  heights.  The 
brace  is  accurately  fitted  to  the  patient's  foot  and  any 
necessary  alterations  are  made  before  the  brace  is  finished. 
Completed,  it  extends  from  the  center  of  the  heel,  where 
it  is  secured  by  a  single  screw,  to  the  heads  of  the  meta- 
tarsals. The  flange  presses  outward  and  slightly  upward 
at  the  astragalo-scaphoid  articulation;  the  leather  of  the 
shoe  pressing,  or  holding,  at  the  two  points  on  the  outer 
side,  the  heel  and  the  forefoot,  so  as  to  produce  adduction 
and  inversion.  This  brace  is  not  absolutely  rigid,  being 
secured  at  the  heel  only;  it  is  of  light  weight;  it  is  ad- 
justable and  can  be  readily  altered  as  occasion  demands ; 


WEAK-FOOT    AND    FLAT-FOOT  97 

and  in  a  well-fitting  shoe,  it  will  retain  the  foot  in  the 
proper  position  with  no  discomfort  to  the  patient. 

The  object  of  some  surgeons  in  applying  a  brace  in 
cases  of  weak-foot,  is  to  obtain  proper  balance,  but  it 
would  seem  that  proper  balance  can  be  obtained  only 
with  the  normally  functionating  foot ;  and  to  treat  a  foot 
from  the  mechanical  comparison  with  skids,  piers,  arches, 
et  cetera,  does  not  appeal  to  the  physiologist. 

Manipulations. —  When  spasm  exists  manipula- 
tions are  clearly  indicated.  In  mild  cases  the  abduction 
and  eversion  may  be  overcome  by  steady  but  gentle  pres- 
sure and  the  corrected  position  retained  by  adhesive  plas- 
ter strapping.  Proper  shoes,  with  the  wedge-shaped 
heels  and  soles  and  possibly  the  extension  heel,  are  ordered 
and  exercises  prescribed.  The  manipulations  should  be 
repeated  and  the  strapping  reapplied  as  often  as  neces- 
sary, usually  once  or  twice  a  week.  No  braces  of  any 
description  should  be  applied  so  long  as  the  spasm  per- 
sists. When  the  foot  is  perfectly  flexible,  when  the 
condition  has  been  converted  into  a  simple  weak-foot,  a 
brace  may  be  applied  if  thought  to  be  desirable. 

Without  Anesthetic. — By  using  the  method  illustrated 
to  overcome  spasm,  all  force  is  applied  directly  toward 
correcting  the  deformity  with  the  least  possible  pain  to 
the  patient.  If  clumsily  performed  much  force  is  wasted 
and  the  pain  is  unnecessarily  severe.  The  patient  should 
be  seated  comfortably,  the  surgeon  standing  facing  him, 
at  such  a  distance,  that  with  the  leg  extended  the  pa- 


98 


DISEASES    AND    DEFORMITIES    OF    THE    FOOT 


tient's  foot  will  be  between  the  surgeon's  knees.  The 
surgeon  now  grasps  the  heel  with  one  hand,  the  kft  heel 
with  the  left  hand,  or  the  right  heel  with  the  right  hand, 
in  such  a  way  that  the  fingers  have  a  firm  hold  on  the 


^^j^s^^^ 


Fig.  36.  Forcible  Correction  of  Abduction 
One  hand  so  grasps  the  hind-foot  as  to  firmly  fix  it  and  offer  the 
thenar  eminence  as  a  fulcrum  while  the  other  hand  forces  the  fore- 
foot into  the  position  of  adduction.  The  force  used  may  be  supple- 
mented by  the  physician  bringing  his  knees  to  bear  against  the  backs 
of  his  hands,  as  recommended  by  Whitman  and  described  in  the  text. 

outer  surface  of  the  os  calcis  while, the  base  of  the  palm 
presses  against  the  inner  border  of  the  foot  close  to  the 
astragalo-scaphoid  joint.  The  forefoot  is  seized  with 
the  other  hand,  the  palm  being  against  the  dorsum.  The 
back  of  the  hand  which  is  holding  the  heel  is  now  brought 


WEAK-FOOT    AND    FLAT-FOOT  99 

against  the  knee  of  the  corresponding  side  of  the  operator, 
and  the  thigh,  just  above  the  knee  of  the  opposite  leg 
of  the  surgeon  is  used  as  an  added  power  to  the  hand 


Figs.  37-38.    Adhesive  Plaster  Strapping 

Both  of  the  straps  are  applied  and  reenforcing  straps  added  as 
necessary. 

Fig.  37  illustrates  the  strap  applied  to  prevent  eversion  at  the  sub- 
astragaloid  joint. 

Fig.  38  shows  the  strap  to  hold  the  fore-foot  in  adduction  and 
dorsal  flexion,  v^fhich  will  be  accompanied  by  some  inversion.  This 
controls  the  movements  at  the  medio-tarsal  joint  and  at  the  ankle 
joint. 

holding  the  forefoot.  Pressure  is  first  made  in  the  direc- 
tion of  plantar  flexion;  steadily  the  foot  is  pressed  into 
the  position  of  equinus  to  the  limit  of  movement.  Then 
inversion,  adduction,  and  dorsal  flexion  are  performed  in 


lOO         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

unison,  very  slowly  and  with  an  even,  steady  pressure. 
If  the  confidence  of  the  patient  is  lost  by  a  sudden  increase 
of  force,  which  will  cause  an  acute  pain,  it  will  be  found 
difficult  to  obtain  perfect  correction.  If  full  correction 
is  not  obtained,  the  strapping  may  be  applied  and  the  next 
seance  may  be  successful,  especially  if  the  feet  are  given 
complete  rest  in  the  interim.  Those  cases  which  have 
too  much  spasm  for  this  treatment  must  be  given  an 
anesthetic,  as  will  presently  be  described. 

Strapping.  —  The  adhesive  plaster  is  applied  to  retain 
the  position  of  inversion,  adduction,  and  dorsal  flexion. 
The  inversion  may  be  retained  by  a  strap  two  inches  wide, 
extending  from  a  little  above  the  external  malleolus, 
around  the  bottom  of  the  foot  and  up  the  inner  side  of 
the  leg  to  the  internal  tuberosity  of  the  tibia.  The  adduc- 
tion and  dorsal  flexion  may  be  secured  by  another  strap 
encircling  the  forefoot,  just  in  front  of  the  medio-tarsal 
joint,  and  coming  from  the  outer  border  of  the  foot 
across  the  plantar  surface  in  a  diagonal  direction  inward 
and  backward,  and  then  extending  up  the  inner  side  of  the 
leg.  These  straps  may  be  reinforced  if  necessary.  A 
cotton  bandage  applied  to  the  entire  foot  and  leg  will 
secure  their  adhesion.  If  the  removal  of  the  strapping 
is  very  painful,  on  account  of  the  pulling  of  the  hairs  of 
the  leg,  benzine  or  some  other  hydro-carbon,  may  be  ap- 
plied with  a  piece  of  cotton,  and  afterward  the  skin  may 
be  wiped  off  with  the  same  material.  When  perfect  flexi- 
bility has  been  obtained,  the  strapping  may  be  discon- 
tinued, but  a  cure  has  by  no  means  been  accomplished 


WEAK-FOOT    AND    FLAT-FOOT 


lOI 


until  the  patient  not  only  can,  but  does,  use  the  foot  at  all 
times  in  the  physiological  way. 

Severe  Cases.  —  When  the  spasm  is  too  severe  to  be 
overcome  with  gentle  means,  when  the  foot  is  practically 
rigid,  an  anesthetic  should  be  given,  the  foot  forced  into 


Fig.  39.    Manipulation  of  Metatarsal  Joints 


an  over-corrected,  not  merely  corrected,  position,  and  put 
in  plaster-of-Paris  from  the  toes  to  the  knee.  After  a 
day  or  so  of  resting  the  feet  in  an  elevated  position,  not 
necessarily  in  bed,  with  the  object  of  reducing  the  swell- 
ing and  discomfort  from  the  traumatism  of  the  operation, 
the  patient  should  be  encouraged  to  stand  and  walk  about. 


I02 


DISEASES    AND    DEFORMITIES    OF   THE    FOOT 


The  more  he  uses  the  feet  while  they  are  in  this  position 
the  better  will  be  the  result.  After  four  weeks,  the  dress- 
ing is  cut  down  and,  if  the  spasm  has  entirely  disappeared, 
the  case  is  treated  as  one  of  simple  weak-foot.  Should, 
however,  any  spasm  remain,  the  foot  must  again  be  put 
up  in  a  position  of  over-correction  in  a  plaster-of-Paris 
dressing. 

If  any  bony  changes  have  taken  place,  which  never- 


FiG.  40.    Manipulation  of  the  Toe- Joints 
The  rigidity  of  the  smaller  joints,  especially  the  toe-joints,  should 
be  relieved  while  the  patient  is  under  an  anesthetic  for  mobilization 
of  the  foot. 

theless  permit  of  restoration  of  the  dome  under  the  anes- 
thetic, the  treatment  with  plaster-of-Paris  and  the  use  of 
the  foot  in  the  over-corrected  position  will  have  to  be 
prolonged  beyond  the  time  necessary  to  correct  deformi- 
ties due  to  the  muscles  and  ligaments  alone.  During 
manipulation  under  an  anesthetic,  attention  should  be 
given  to  all  the  joints  of  the  foot :  the  anterior  arch  should 
be  restored  and  full  flexion  (of  all  the  toes)  obtained. 


WEAK-FOOT    AND    FLAT-FOOT  IO3 

Plaster-of -Paris  Dressing.  —  The  object  of  applying 
plaster-of-Paris  after  manipulation  of  the  foot  for  spas- 
modic flat-foot,  is  not  only  to  retain  the  foot  in  the  im- 
proved position,  but  to  cure  a  more  or  less  severely 
contused  and  sprained  foot  as  well.  Therefore  perfect 
immobilization  must  be  had,  while  at  the  same  time  pro- 
vision is  made  for  the  swelling  which  must  follow  during 
the  first  twenty-four  hours. 

Long  strips  of  cotton- wadding  are  placed  between  the 
toes.  They  extend  from  the  instep,  through  the  clefts  of 
the  toes,  to  the  middle  of  the  sole.  They  should  be  of 
sufficient  size  to  keep  the  toes  slightly  separated,  thus 
giving  a  broader  base  to  the  forefoot  and  preventing  the 
toes  from  being  crumpled  up  and  also  keeping  adjoining 
skin  surfaces  apart.  Cotton-wadding  is  then  applied 
from  the  tip  of  the  great  toe  to  the  tubercle  of  the  tibia. 
The  easiest  way  to  apply  this,  is  to  have  the  wadding 
cut  into  strips  three  inches  wide  and  rolled  on  itself 
the  same  as  a  bandage.  The  thickness  to  which  this 
is  to  be  applied  must  depend  upon  the  amount  of  swell- 
ing which  may  be  expected.  Usually  it  should  be  about 
half  an  inch  thick  over  the  entire  part,  with  an  extra 
thickness  of  half  an  inch  over  the  instep  and  about  the 
malleoli.  Over  this  wadding  a  flannel  bandage  may  be 
applied  for  the  purpose  of  retaining  the  wadding  in  place 
while  the  plaster  bandages  are  being  put  on.  This  flan- 
nel bandage  is  for  no  other  purpose;  and  care  must 
be  exercised  that  it  is  not  made  to  bind  at  any  part. 
Many  surgeons  teach  that  a  plaster  dressing  should  begin 


I04 


DISEASES    AND    DEFORMITIES    OF   THE   FOOT 


at  the  metatarsal-phalangeal  joints,  but  if  the  entire 
toes  are  included  there  will  be  much  less  likelihood  of 
serious  disturbance  with  the  circulation. 

To  hold  the  foot  in  the  over-corrected  position,  not 


Figs  41-42.  The  Plaster-of-Paris  Bandage 
It  should  extend  from  the  tips  of  the  toes  to  the  tibial  tubercle. 
It  should  be  laid  on  and  not  bound  on.  Spiral  turns  are  less  likely 
to  offer  ridges  than  are  figure-of-eight  turns.  Antero-posterior 
compression  of  the  completed  plaster  over  the  forefoot  assures 
plenty  of  room  for  the  toes.  Lateral  compression  above  the  heel 
will  bulge  the  plaster  out  backward  and  relieve  the  tendo  Achillis 
from  all  danger  from  pressure. 

Fig.  42  illustrates  the  making  of  a  pad  to  be  incorporated  into  the 
plaster  over  the  bottom  of  the  foot  and  provide  a  sole.  It  may  be 
easily  built  up  on  one  side  or  the  other  or  under  the  toes  or  under 
the  heel  so  as  to  act  as  a  corrective  force  when  the  plaster  is  used 
as  an  ambulatory  splint. 


a  little  skill  and  dexterity  are  needed.  From  the  begin- 
ning of  the  application  of  the  plaster  bandages,  until 
the  dressing  is  well  set,  the  foot  should  be  held  con- 
tinuously in  the  desired  attitude.  If,  after  a  few  layers 
of  the  bandage  have  been  put  on,  the  position  of  the  foot 


WEAK-FOOT    AND    FLAT-FOOT  IO5 

is  altered,  wrinkles  will  be  formed,  which  may  cause 
pressure  sores.  The  assistant  should  insert  the  fingers 
of  one  hand  between  the  dressing  and  the  skin,  grasp 
the  toes  firmly,  and  hold  the  foot  in  the  dorsal  flexed, 
adducted,  and  inverted  position.  The  other  hand  is 
used  to  press  against  the  inner  side  of  the  leg  so  as  to 
help  in  obtaining  the  inversion  and  adduction.  If  a  good 
grip  is  obtained  of  the  toes,  that  hand  will  not  need  to 
be  removed  until  the  dressing  is  finished. 

The  plaster-of -Paris  bandages  should  be  two  or  three 
inches  wide.  They  are  placed,  one  at  a  time,  in  warm 
water  until  thoroughly  soaked,  and  as  one  is  being  used 
another  is  put  into  the  water.  In  applying  the  bandage 
care  must  be  taken  that  it  is  not  bound  on  with  any 
firmness :  each  layer  is  "  laid "  on,  as  the  bandage  is 
unrolled  upon  the  foot  and  leg.  It  should  not  be  held 
in  the  hand  as  when  a  bandage  is  used  in  applying  splints 
or  in  securing  the  dressing  after  an  open  operation,  but  al- 
lowed to  rest  on  the  part  and  to  be  rolled  about  the 
foot  in  such  a  way  that,  as  it  unrolls,  the  layers  may 
be  left  where  they  fall  without  any  undue  pressure. 
Should  any  part  present  a  wrinkle  it  must  be  straightened 
out  so  that  the  bandage  lies  flat  in  every  instance. 

A  most  important  part  in  the  technique  is  the  thorough 
rubbing  of  each  layer.  If  an  assistant  does  nothing  but 
rub  the  layers  of  bandage  as  they  are  applied,  until  the 
plaster  is  perfectly  set,  it  will  be  found  that  a  much 
greater  hardness  is  produced  than  if  this  is  neglected. 
Before  the  last  layer  is  applied  about  the  toes  and  at 


I06  DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

the  upper  end,  the  wadding  is  turned  over  the  plaster 
and  the  last  layer  of  bandage  is  used  to  secure  the  turned 
over  part.  This  will  pad  these  edges  which  might  other- 
wise cause  excoriations.  Finally,  talcum  powder  may 
be  rubbed  into  the  entire  dressing,  filling  any  pores  in 
the  last  layer  of  bandage  and  giving  a  smooth  finish 
which  will  permit  washing  of  the  bandage  should  it 
become  soiled.  Before  the  plaster  has  become  hardened, 
the  forefoot  about  the  metatarsals,  should  be  compressed 
in  the  vertical  diameter,  flattening  it  and  making  more 
room  for  the  toes. 

Operations. — For  the  cure  of  these  conditions  of  the 
foot,  operations  are  seldom  necessary.  Manipulations, 
patiently,  thoroughly,  and  repeatedly  carried  out,  will, 
in  the  great  majority  of  instances,  effect  a  cure. 

Tenotomy. —  The  operation  which  is  the  most  fre- 
quently called  for,  is  the  simple  one  of  tenotomy.  The 
peroneal  tendons  are  the  ones  which  most  frequently 
need  to  be  divided.  It  is  well  to  be  prepared  to  do  this 
whenever  a  flat-foot  is  to  be  manipulated  under  an  an- 
esthetic. After  painting  the  skin  about  the  external 
malleolus  with  iodine,  a  small  tenatome  is  inserted  two 
inches  above  the  tip  of  the  malleolus  close  to  the  pos- 
terior border  of  the  bone  and  both  tendons  divided 
subcutaneously.  Division  of  the  tendo  Achillis  should 
be  done  whenever  manipulations  fail  to  restore  the  nor- 
mal range  of  dorsal  flexion.  As  the  foot  is  to  be  treated 
in  plaster-of -Paris  subsequently  no  hesitancy  need  be 
felt  in  doing  these  or  other  tenotomies  if  the  sought-' 


WEAK-FOOT    AND    FLAT-FOOT  IO7 

for  over-correction  can  be  the  better  secured  by  so  doing, 
as  the  immobihzation  will  assure  one  of  perfect  union. 

Excision. —  Excision  of  the  head  of  the  astragalus : 
"  This  is  the  best  operation  on  the  whole,"  says  Cheyne, 
but  according  to  this  surgeon  it  may  leave  a  weak  dome, 
necessitating  the  continual  use  of  a  support. 

Arthrodesis. —  Ogston's  operation :  an  arthrodesis 
of  the  astragalo-scaphoid  joint.  The  incision  is  made 
from  just  below  the  internal  malleolus,  forward  to  just 
below  the  tubercle  of  the  scaphoid,  avoiding  the  tendon 
of  the  tibialis  anticus.  The  cartilage  on  both  articular 
surfaces  is  removed  and  also  any  bone  necessary  for 
the  restoration  of  the  dome.  A  peg  of  ivory  or  of 
other  material  is  inserted  through  a  drilled  hole,  pass- 
ing from  the  scaphoid  into  the  head  of  the  astragalus. 
The  foot  is  kept  in  a  plaster-of-Paris  dressing  for  four 
weeks  and  a  support  is  worn  for  six  weeks  longer,  or 
until  ankylosis  is  firmly  established. 

Tarsectomy. —  Internal  tarsectomy  is  done  to 
shorten  the  internal  border  of  the  foot.  By  removing 
a  wedge-shaped  piece  of  the  bony  formation  of  the  foot, 
— regardless  of  just  what  bones  are  attacked, — with  the 
base  of  the  wedge  on  the  inner  side  and  facing  in  a  di- 
rection inwards  and  upwards  rather  than  directly  in- 
wards, and  the  apex  outward  and  downward,  reaching 
quite  to  the  external  border,  one  may  restore  the  adduc- 
tion and  the  inversion.  The  writer  has  had  no  ex- 
perience with  this  operation,  does  not  believe  it  is  often 
necessary,  does  not  find  it  very  popular  among  his  con- 


I08  DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

freres  and  would  use  it  only  after  every  other  effort 
had  failed  in  a  foot  which  was  practically  useless  on 
account  of  pain  from  the  deformed  position. 

Scaphoidectomy. —  This  was  done  by  Golding-Bird 
in  four  cases,  in  two  of  which  the  head  of  the  astragalus 
was  also  removed.  All  were  relieved  of  the  pain  from 
the  removal  of  pressure  on  the  outer  side,  and  in  one 
case  the  arch  was  restored :  in  this  one  there  was  added 
a  subcutaneous  sawing-through  of  the  whole  tarsus,  thus 
admitting  of  rotation  and  adduction  of  the  front  on  the 
back  part  of  the  foot. 

Post-Operative  Treatment. —  Post-operative  condi- 
tions, even  after  nothing  more  than  a  manipulation  under 
an  anesthetic,  may  be  a  source  of  delaying  a  cure.  Ad- 
hesions may  form  which  cause  great  pain  upon  attempts 
at  the  full  range  of  movements. 

Douching. — The  easiest  remedy  for  this  condition 
and  at  the  same  time  the  best,  is  douching  alternately 
with  cold  and  hot  water.  The  nervous  shock  to  the 
dilators  and  contractors  of  the  vessels,  creates  a  splendid 
local  circulation;  and  the  force  of  the  water,  if  the  douch- 
ing is  rightly  done,  is  of  an  added  value.  The  hot  water 
should  be  as  hot  and  the  cold  as  cold  as  the  patient  can 
bear.  Two  pitchers  may  be  used,  each  holding  half  a 
gallon,  or  else  smaller  pitchers,  refilled  as  often  as  neces- 
sary, until  about  a  half -gallon  of  each  water  is  used. 
The  foot  is  placed  over  a  tub  of  some  sort  to  catch  the 
water.  With  one  of  the  pitchers  held  eight  to  twelve 
inches  above  the  foot,  the  water  is  poured  onto  it  in 


WEAK-FOOT    AND    FLAT-FOOT  IO9 

a  small  stream  for  thirty  to  fifty  seconds,  the  time  being 
regulated  by  the  sensations  of  the  patient:  the  foot 
should  feel  quite  hot  when  the  hot  water  is  changed 
to  the  cold  and  quite  cold  when  the  cold  water  is  changed 
to  the  hot.  The  pitcher  may  be  held  as  high  as  20  or 
24  inches  above  the  foot  if  desirable,  and  this  is  usually 
advisable  after  the  first  few  treatments,  as  the  greater 
force  is  very  beneficial.  It  may  be  possible  to  use  a 
spray  from  the  tap  when  the  tap  has  both  hot  and  cold 
water  connections,  but  this  is  seldom  satisfactory  as 
the  hot  water  usually  becomes  too  hot  in  a  very  few 
moments.  When  douching  is  impossible,  we  find  that 
using  two  foot-tubs  or  pails,  one  containing  hot  and  the 
other  cold  water,  and  having  the  patient  put  the  foot 
alternately  into  one  and  then  into  the  other,  is  productive 
of  excellent  results.  Under  no  circumstances  should  hot 
water  alone  be  used.  For  tired,  aching  feet,  hot  water 
is  soothing  but  it  is  not  good  for  the  circulation.  Cold 
water,  followed  by  a  vigorous  towel-rubbing,  is  always 
to  be  preferred  when  inflammation  is  absent. 

It  will  be  found  that  immediately  after  the  douching 
both  active  and  passive'  movements  are  much  freer. 
The  patient  should  flex  and  extend  the  foot  at  the  ankle, 
flex  and  extend  the  toes,  invert  and  evert  the  foot  and 
circumduct  the  forefoot. 

Liniments. —  Because  they  provide  a  source  of 
massage,  and  are  cooling  to  any  inflammatory  condition, 
liniments  may  be  advantageously  prescribed.  A  lini- 
ment which   is  more  satisfactory   in  many   ways   than 


no  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

the  ordinary  ones  of  the  pharmacopoeia,  is  the  one  recom- 
mended by  Shaffer: 


^. 

Chloral  hydrate 

Menthol 

Pulv.  gum  camphor 

aaS  III 

Olei  cajuput 

3  VI 

Tincturse  belladonnse 

3  IV 

Spirit!  vini  rect.  q.  s. 

ad.  §  IV 

M.  Sig.  Liniment.     Poison.     Use  as  directed. 

CHAPTER  V 
CONGENITAL  CLUB-FOOT 

The  fixation  of  the  foot  at  birth  in  a  position  in  which 
the  normal  foot  can  be  placed,  or  an  exaggeration  thereof, 
is  called  congenital  club-foot.  If  untreated,  in  the 
severer  forms,  when  the  child  begins  to  walk,  it  will 
walk  on  the  ankle  and  hence  the  name,  talipes. 

Varieties. —  If  the  foot  is  fixed  in  the  position  of 
plantar  flexion,  with  the  movements  normal  in  the  ver- 
tical; medio-tarsal,  and  in  the  longitudinal;  sub-astraga- 
loid  axes,  it  is  called  talipes  equinus.  If  the  foot  is 
fixed  in  the  position  of  dorsal  flexion,  with  the  other 
movements  normal,  it  is  talipes  calcaneus.  If  move- 
ment at  the  transverse  axis,  the  ankle  joint,  is  normal  and 
the  foot  is  fixed  in  the  position  of  inward  rotation  on 
the  longitudinal  axis  and  adduction  on  the  vertical  axis, 
the  condition  is  named  talipes  varus;  or  if  the  fixation 
is  limited  to  the  same  axes  but  the  foot  is  everted  and 
abducted,  talipes  valgus. 

There  may  be,  however,  a  combination  of  one  of  the 
first  two  deformities  with  one  of  the  latter  two,  such 
as  talipes  equino-vanis,  talipes  equino-valgus,  or  talipes 
calcaneo-varus  or  talipes  calcaneo-valgus.  There  are, 
in  addition,  cases  in  which  the  dome  of  the  foot  is  ab- 

III 


112  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

normally  high  or  abnormally  low,  when  the  condition 
of  cavus  or  planus  exists. 

Normally,  at  birth,  the  foot  is  slightly  in  the  posi- 
tion of  equino-varus  and  the  arch  is  not  well  formed. 
It  does  not  constitute  a  pathological  condition,  when  by 
voluntary  or  reflex  action  the  muscles  can,  unassisted, 
execute  the  normal  movements. 

A  classification  of  the  deformities  of  club-foot  based 
upon  the  nerve  supply  to  the  muscles,  was  arranged  by 
Bonnet,  and  in  spite  of  its  imperfections,  it  is  very  use- 
ful. Malgaigne,  as  quoted  by  Lannelongue,  criticised 
it  because  the  tibialis  anticus,  supplied  from  the  external 
popliteal,  elevates  the  inner  border  and  valgus  could 
not  accompany  its  contraction;  and  also  because  in  Bon- 
net's tabulation  of  the  degrees  of  club-foot  he  places 
calcaneus  as  the  last  or  fifth  under  external  popliteal 
club-foot,  not  admitting  therefore  that  it  exists  as  a 
simple  variety.     This  classification  is : 

Internal  Popliteal  Club-foot. 

1.  Elevation  of  the  heel. 

2.  Antero-posterior  flexion  of  the  foot  on  itself. 

3.  Abduction  of  the  fore-foot. 

4.  Turning  of  the  heel  inward. 

5.  Increase  of  the  dome  of  the  foot. 

External  Popliteal  Club-foot. 

5.  Lowering  of  the  heel. 

4.  Forced  extension  of  the  foot  on  itself. 

3.  Adduction  of  the  fore-foot.  : 


CONGENITAL    CLUB-FOOT  II3 

2.  Turning  of  the  heel  outward. 

I.  Lowering  of  the  dome  of  the  foot. 

Frequency. —  The  frequency  of  congenital  club- 
foot is  one  in  every  two  thousand  births  (Lannelongue) 
to  one  in  every  eleven  hundred  (Bessel-Hagen).  In 
comparison  with  other  deformities  it  bears  the  relation 
of  one  to  five.  Tamplin  reported  that  at  the  Royal  Or- 
thopedic Hospital  in  10,217  deformities  of  all  kinds, 
1,780  were  congenital  club-foot.  Kirmisson  found  it 
a  little  less  frequently,  166  cases  out  of  1,100  deformi- 
ties at  the  Enfants  Assistes;  and  Bessel-Hagen  placed 
the  frequency  at  one  in  ten.  Lechiberder,  quoted  by 
Lannelongue,  in  15,229  births  found  the  following  ab- 
normalities; club-foot  8,  spina  bifida  4,  hare-lip  8,  um- 
bilical hernia  JJ,  hydrocephalus  3,  anencephalus  2,  imper- 
ferate  anus  i,  hypospadias  12,  extrophie  of  the  bladder 
I,  and  encephalocile  2. 

It  is  very  unusual  to  see  different  forms  of  the  de- 
formity in  the  same  patient.  Whitman  reports  eighteen 
cases,  less  than  3  per  cent. ;  Ketch  three  cases,  slightly 
more  than  3  per  cent. ;  and  Kirmisson  about  the  same 
percentage. 

It  is  more  often  double  than  single,  when  unilateral 
the  right  is  more  often  affected  than  the  left  (Whitman, 
Ketch,  and  Kirmisson)  ;  but  Bessel-Hagen  found  fifty- 
one  left  to  forty-one  right. 

Boys  are  more  frequently  affected  than  girls. 

Of  the  varieties,  equino-varus  is  by  far  the  most  com- 


114         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

men,  three-quarters  of  all  cases  (Whitman).  Pure  val- 
gus and  pure  equinus  are  rare,  according  to  Walsham 
and  Hughes,  Kirmisson,  and  others.  The  existence  of 
pure  congenital  equinus  is  denied  by  some.  It  was  seen 
but  twice  in  twelve  years  by  Walsham.  Whitman  re- 
ports 40  cases  of  equinus  and  123  cases  of  valgus  out 
of  1,660  cases. 

Etiology. —  The  etiology  of  congenital  club-foot 
has  received  the  careful  study  of  many  eminent  phy- 
sicians. Scarpa,  Little,  Lannelongue,  Volkman,  Hoffa, 
Berg,  J.  Guerin,  Parker,  Walsham,  and  Scudder  have 
perhaps  thrown  more  light  upon  the  matter  than  any 
other  students.  They  by  no  means  reached  the  same 
conclusions  and  no  one  has  as  yet  succeeded  in  advanc- 
ing a  theory,  regarding  the  cause  of  this  deformity, 
which  encompasses  all  cases,  meets  the  laws  of  em- 
bryology, and  explains  satisfactorily  the  pathological 
changes.  These  various  theories, —  and  they  are  all 
theories, — are  usually  termed  the  germ  theory,  the  nerve 
theory,  the  bone  theory,  the  pressure  theory,  and  the 
theory  of  abnormal  fetal  movements. 

Although,  in  a  few  instances,  this  deformity  has  been 
traced  through  several  generations,  its  appearance  is 
generally  an  isolated  case  in  the  family  and  all,  I  believe, 
are  agreed  that  heredity  can  not  be  a  factor.  Consan- 
guinary  marriages  have  been  cited  as  of  possible  etio- 
logical significance,  but  any  connection  is  only  theoretical. 
Broadhurst  believes  that  impressions  and  emotions  dur- 


CONGENITAL    CLUB-FOOT  II5 

ing  pregnancy  may  cause  club-foot ;  but  few,  I  believe,  will 
agree  with  this  opinion. 

The  germ  theory  is  satisfactory  where  there  is  evi- 
dence of  positive  germ  effect,  as  absence  of  bones ;  but 
it  is  not  acceptable  in  the  vast  majority  of  cases. 

The  nerve  theory,  that  some  nerve  lesion,  perhaps 
transitory  and  functional  only,  has  caused  the  deformity 
in  the  same  way  as  spastic  paralysis  may  cause  the  de- 
formity post-natal,  had  for  its  principal  supporters, 
Little,  Adams,  and  J.  Guerin.  According  to  this  theory 
the  muscles  hold  the  feet  in  the  deformed  position  while 
the  changes  in  the  structures  follow  in  adaptation  to  the 
new  position. 

The  bone  theory  attributes  the  deformity  to  a  primary 
abnormality  in  the  bones,  chiefly  the  astragalus,  which 
retains  the  foot  in  the  deformed  position;  and  the  soft 
structures  accommodate  themselves  to  this  position.  As 
will  be  seen  when  we  come  to  study  that  bone,  the  fetal 
astragalus  has  the  direction  of  its  neck  very  similar  to 
that  of  the  talipedic  astragalus,  more  inclined  down- 
ward and  inward  than  the  normal  astragalus  at  birth. 
However,  the  talipedic  astragalus  shows  by  its  scaphoidal 
articular  facet  that  there  was  some  other  influence  at 
work  to  alter  the  relations  between  the  tarsal  bones. 

The  pressure  theory  holds  that  the  foot  was  held  by 
pressure,  uterine  walls,  twins,  tumors,  abnormalities 
such  as  hydrocephalus,  adhesions  of  the  amnion,  etc., 
in  a  deformed  position  for  such  a  length  of  time  that 


Il6         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

the  alterations  in  bone,  ligaments,  and  muscles  are  per- 
mitted to  follow.  Hippocrates,  Galen,  Scarpa,  Pare, 
Volkman,  Hoffa,  Shattock,  and  Parker  are  among  the 
supporters  of  this  theory.  Its  opponents  claim  that 
there  are  other  parts  which  are  retained  during  fetal  life 
for  some  time  in  one  position  without  the  creation  of 
deformities  such  as  flexed  neck,  arms,  etc.,  and  further- 
more that  pressure  could  scarcely  produce  the  extreme 
elevation  of  the  os  calcis  which  is  present  in  severe 
cases.  Pressure  sores  have  been  discovered  on  fetuses 
and  new-born  children,  but  they  are  rare  and  can  not 
be  considered  of  much  value  in  confirmation  of  this 
theory. 

The  theory  of  abnormality  in  fetal  movements,  as 
advocated  by  Eschricht,  Berg,  and  Kocker,  is  that  instead 
of  the  positions  of  the  lower  extremities  being  altered 
in  utero,  especially  during  the  third  and  fourth  months, 
the  one  position  is  continued  for  such  a  long  time  that 
shortening  of  the  muscles  and  ligaments  results,  together 
with  changes  in  the  bones.  The  deformity  results,  in 
both  this  and  the  pressure  theory,  from  too  long  reten- 
tion in  one  position. 

General  Appearance. — In  congenital  talipes  equino- 
varus,  if  only  one  foot  is  affected,  its  external  appear- 
ance may  easily  be  compared  with  the  normal  one:  it  is 
smaller;  its  color  proclaims  a  poorer  circulation;  its  toes 
are  pointed  downward  and  inward  toward  the  other  foot ; 
its  sole  is  turned  inward,  upward,  and  backward  and  the 
dorsum  faces  forward,  outward,  and  downward;  the  ex- 


CONGENITAL   CLUB-FOOT  1 17 

ternal  border  is  much  rounded  and  the  internal  is 
markedly  concave;  there  may  be  an  angle  interrupting 
this  concavity  at  about  its  center;  the  external  malleolus 
is  more  prominent  and  the  internal  may  not  be  apparent ; 
the  tuberosity  of  the  os  calcis  is  smaller,  elevated,  and 
near  to  or  quite  touching  the  external  malleolus.  On  the 
dorsum,  there  may  be  seen  and  easily  felt,  the  astragalus 
protruding  from  its  mortise.  The  internal  malleolus 
may  be  felt  to  be  apparently  in  advance  of  its  normal 
position  and  the  external  will  seem  to  have  taken  a 
position  nearer  the  back  of  the  leg,  due  to  the  inward 
deflection  of  the  astragalus  and  the  foot  as  a  whole. 
Close  to  the  internal  malleolus,  sometimes  beneath  it, 
may  be  felt  the  tuberosity  of  the  scaphoid.  The  head  of 
the  astragalus  will  be  slightly  above  and  behind  the 
scaphoid  tubercle. 

Explanation  of  Appearance. —  What  has  taken 
place  may  be  the  more  easily  understood  by  keeping  in 
mind  the  three  principal  axes  of  the  foot,  and  imagining 
each  movement  about  these  axes  as  being  strongly  ac- 
centuated. The  movement  on  the  transverse  axis,  in 
the  direction  of  plantar  flexion,  is  so  exaggerated  that 
the  trochlear  surface  of  the  astragalus  is  protruded  for 
perhaps  two-thirds  of  its  length,  forwards,  out  of  its 
socket.  Attention  has  been  called  to  the  direction  this 
bone  takes  in  plantar  flexions;  not  only  about  a  trans- 
verse axis  but  also  about  a  vertical  axis  which  is  situated 
at  about  the  internal  malleolar  facet,  an  inward  rotation, 
and  consequently  we  find  the  head  directed  inward  as 


Il8         DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

well  as  downward,  instead  of  simply  forward  and  down- 
ward as  it  would,  were  the  movement  limited  to  an 
antero-posterior  plane.  On  the  antero-posterior  axis, 
passing  through  the  sub-astragaloid  joint,  the  foot  has 
been  strongly  inverted  so  that  the  entire  plantar  surface 
is  directed  inward.  There  is  also  some  movement  in 
this  joint  about  a  vertical  axis  and  in  this  condition  this 
movement,  normally  not  marked,  is  exaggerated,  so  that 
there  is  a  twisting  inward  of  the  anterior  part  of  the 
OS  calcis  and  outward  of  its  posterior  tuberosity.  Thus 
an  alteration  is  produced  in  the  normal  relation  of  the 
long  axis  of  the  os  calcis  with  that  of  the  astragalus. 
Through  the  vertical  axis,  at  the  medio-tarsal  joint,  ad- 
duction of  the  forefoot  has  taken  place  in  the  normal 
direction  of  the  movement  here  but  unusually  pronounced. 
At  this  joint  too,  the  usually  but  slightly  marked  move- 
ment of  rotation,  will  be  marked  in  an  inward  and  up- 
ward direction. 

Changes  in  the  Bones. —  The  most  marked  changes 
in  the  bones  will  be  found  in  the  astragalus  and  the  os 
calcis :  the  astragalar  neck  will  be  directed  inward  and 
downward  instead  of  forward  and  very  slightly  inward 
and  downward.  In  the  fetus  it  is  normally  turned  in- 
ward to  about  35.75  degrees,  in  the  adult  to  about  12.32 
and  in  the  club-foot  to  about  50.75  (Scudder).  The 
astragalar  head  is  much  attenuated  and  presents  an  ex- 
tension backward  of  its  articular  surface.  There  may 
be  a  ridge  across  the  articular  surface  separating  the 
posterior  part,  which  is  in  articulation  with  the  scaphoid, 


CONGENITAL    CLUB-FOOT  1 19 

from  the  anterior  part,  which,  in  the  deformed  position, 
is  left  uncovered  by  the  scaphoid. 

The  OS  calcis  is  not  only  plantar  flexed  and  rotated 
on  its  long  axis  and  turned  on  a  vertical  axis,  so  that 
its  anterior  extremity  is  inside  of  its  normal  position, 
as  already  pointed  out,  but  there  is  an  inward  twist, 
postero-anteriorly,  of  the  bone:  an  intrinsic  twist.  The 
superior  surface  of  the  os  calcis  looks  forward  and 
inward.  The  tuberosity  is  small  and  may  be  in  contact 
with  the  external  malleolus.  The  facet  for  articulation 
with  the  cuboid  looks  markedly  downward  and  inward. 
All  the  bones  of  the  foot  are  undeveloped,  otherwise 
the  rest  are  nearly  normal  in  their  characteristics. 

The  abduction  and  rotation  of  the  forefoot  at  the 
medio-tarsal  joint  carries  the  scaphoid  inward,  back- 
ward, and  upward,  so  that  it  articulates  with  the  back 
part  of  the  astragalar  head  and  may  touch  the  internal 
malleolus. 

The  cuboid  is  likewise  altered  in  its  relations  to  the 
OS  calcis;  its  superior  surface  looks  outward  and  down- 
ward. The  malleoli  are  not  much  altered  in  develop- 
ment. There  is  no  change  in  their  relative  position  to 
each  other,  although  the  position  of  the  foot  gives  the 
appearance  of  the  shifting  of  the  external  malleolus 
to  a  more  posterior  position.  There  may  be  an  articu- 
lar facet  on  the  external  malleolus  for  the  os  calcis  and 
one  on  the  internal  malleolus  for  the  scaphoid. 

The  bones  of  the  leg  may  be  twisted  in  their  long 
axis,  so  that  were  the  foot  normal  it  would  nevertheless 


I20         DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

be  turned  inward  in  its  relation  to  the  knee.  The  femur 
may  be  twisted  inward  on  its  long  axis  and  the  femoral 
neck  may  be  so  bent  that  it  is  slightly  concave  forward 
and  adds  to  the  inward  twist  of  the  shaft  of  the  bone. 

Changes  in  Ligaments  and  Muscles. —  The  liga- 
ments on  the  inner  side  of  the  ankle  and  foot  and  the 
inner  half  of  the  plantar  ligaments  and  the  posterior 
ligaments,  are  all  more  or  less  shortened.  The  muscle- 
tendons  passing  over  the  ankle-joint  are  displaced  to 
an  extent  depending  on  the  changed  position  of  their 
points  of  insertion.  The  tendon  of  the  tibialis  anticus 
will  lie  close  to  the  internal  malleolus,  either  in  front 
of  it  or,  in  severe  cases,  to  its  inner  side,  as  the  internal 
cuneiform  and  the  first  metatarsal  are  in  that  direction. 
The  tendons  of  the  other  anterior  muscles  will  be  like- 
wise displaced  inwards  to  a  corresponding  degree. 

The  tibialis  posticus,  instead  of  turning  forward  be- 
neath the  malleolus,  continues  downward  to  the  tubercle 
of  the  scaphoid;  and  as  the  scaphoid  approximates  and 
may  even  articulate  with  the  malleolus,  the  portion  of 
this  tendon  below  the  malleolus  may  be  very  short  and 
difficult  to  define.  The  tendon  of  the  flexor  longus  digi- 
torum  and  the  flexor  longus  pollicis  are  displaced  in- 
ward from  their  normal  position  in  proportion  to  the 
degree  of  the  deformity.  The  peroneal  tendons  have 
deeper  grooves  than  usual  on  the  external  surface  of  the 
OS  calcis.  The  longus,  instead  of  crossing  the  cuboid 
in  its  course  to  its  insertion,  may  pass  posterior  to  the 
cuboid.     The  tendo  Achillis  is  displaced  outward  with 


Plate  II. — Unilateral  Congenital  Talipes  Equino- Varus 


The  following  characteristics  are  illustrated  i  the  atrophy  of  the 
leg  and  foot ;  the  elevated  position  of  the  malleoli  due  to  the 
equinus  ;  the  callus  over  the  head  of  the  os  calcis  where  most  of 
the  weight  Is  borne ;  the  rolling  up  of  the  forefoot  on  a  longi- 
tudinal axis,  plantar-ward,  the  little  toe  being  out  of  sight  and 
the  fourth  turned  inward  and  upward.  This  foot  was  cured  by 
multiple  tenotomies  and  resection  of  the  head  of  the  os  calcis, 
followed    by   a   brace. 


CONGENITAL    CLUB-FOOT 


121 


the  tuberosity  of  the  os  calcis  and  lies  closer  to  the  fibula 
than  normally. 

The  blood  vessels  and  nerves  are  shortened,  accord- 
ing to  some  observers,  while  others  believe  that  the  ves- 
sels are  not  actually  shortened  but  are  tortuous. 

Pathology  After  Use. —  If  such  a  foot  as  has  been 
described  is  walked  on,  all  the  deformities  become  more 


Fig.  43.    Congenital  Talipes  Equino- Varus 
Illustrating  a  congenital  club-foot  which  has  been  walked  upon. 
Note  the  longitudinal  crease  in  the  plantar  surface  and,  less  marked, 
the  transverse  crease  in  front  of  the  heel. 

pronounced;  the  equinus,  the  inversion,  and  the  adduc- 
tion. The  dorsum  may  eventually  come  in  contact  with 
the  ground.  Usually,  however,  it  is  the  anterior  and 
external  part  of  the  os  calcis  which  receives  the  most 
weight,  and  a  callus,  with  a  bursa  beneath  it,  is  generally 
found  in  this  location. 

The  plantar  surface,  facing  inward,  upward,  and  back- 
ward, will  become  narrower  from  pressure.     This  pres- 


122  DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

sure  tends  to  roll  the  foot  upon  itself  and,  in  consequence, 
a  longitudinal  furrow  will  be  found  in  the  plantar  surface 
of  a  congenital  club-foot  which  has  been  walked  on. 
Just  in  front  of  the  heel,  at  the  medio-tarsal  joint,  a 
transverse  groove  may  be  seen  which  will  be  most  marked 
between  the  posterior  part  of  the  longitudinal  groove  and 
the  internal  malleolus. 

Through  use,  the  os  calcis  will  be  raised  still  higher, 
so  that  the  bone  may  assume  a  position  parallel  to  the 
fibula  and  may  even  articulate  with  it,  a  capsule  some- 
times completing  the  joint.  Its  posterior  superior  ar- 
ticular facet  may  be  altered  in  the  direction  of  its  long 
diameter  so  as  to  be  directed  from  behind,  forward  in- 
stead of  forward  and  slightly  outward,  or,  in  severe 
cases,  it  may  be  directed  forward  and  markedly  inward. 
Attention  is  called  to  these  changes  by  Walsham  and 
Hughes,  and  interpreted  by  them  as  resulting  from  an 
altered  part  of  the  bone  being  brought  into  the  articula- 
tion and  not  from  a  shifting  of  the  direction  of  the 
normal  articular  surfaces.  The  anterior  surface  of  the 
OS  calcis  is  much  altered.  The  cuboid  in  a  used  tahpedic 
foot  of  this  variety  is  still  further  displaced  internally 
and  the  position  of  the  articular  surface  on  the  os  calcis, 
for  the  cuboid,  has  not  only  an  absence  of  articular 
cartilage  but  presents  an  over-growth  of  bone,  a  tuber- 
osity. This  has  probably  been  produced  by  irritation, 
as  it  is  here  that  the  greatest  support  is  obtained  in  walk- 
ing and  standing.  This  tuberosity  is  of  great  importance 
in   attempting   to   replace   the   cuboid   in   reducing   de- 


CONGENITAL    CLUB-FOOT  I23: 

formity.  The  internal  surface  of  the  os  calcis  presents 
a  new  articulation  for  the  cuboid.  This  surface  has  its 
concavity  increased  and  the  external  surface,  its  convex- 
ity increased. 

The  astragalus  will  have  lost  the  articular  cartilage 
from  the  anterior  protruding  part  of  the  trochlear.  The 
posterior  part  of  the  trochlear  will  be  separated  from 
the  inferior  part  of  the  bone  only  by  a  ridge.  The  ex- 
posed inner  portion  of  the  head,  the  anterior  portion  of 
the  talipedic  head,  will  have  lost  its  cartilage.  The  neck 
will  have  a  decided  downward  as  well  as  backward  in- 
clination and  will,  according  to  Walsham  and  Hughes, 
be  elongated.  On  the  external  surface,  in  front  of  the 
external  malleolus,  there  will  be  found  a  bony  deposit 
which  would  interfere  with  the  outer  rotation  of  the 
bone  into  its  normal  position. 

The  other  bones  will  show  some  changes,  but  none  that 
are  of  equal  importance  to  those  of  the  os  calcis  and 
astragalus. 

All  the  above  changes  will  be  found  in  the  congenital 
talipedic  foot  of  the  equino-varus  variety,  which  has 
been  used,  varying  in  the  degree  of  their  pronounce- 
ment with  the  degree  of  deformity  at  birth  and  with  the 
amount  the  foot  has  been  employed. 

Confirmation  of  Structural  Changes. —  Whereas  the 
changes  in  the  muscles,  ligaments,  and  bones  during  in- 
fancy are  such,  usually,  as  can  be  overcome  with  com- 
parative ease,  in  childhood  and  adult  life  they  become 
more   and   more    serious    obstacles   to   a   cure.     Slight 


124         DISEASES   AND   DEFORMITIES   OF  THE   FOOT 

manual  traction  may  at  the  beginning  be  sufficient  to 
restore  the  normal  position;  but  as  months  are  allowed 
to  pass  without  treatment,  tenotomies  become  more  and 
more  necessary.  Further  neglect  may  result  in  the  im- 
possibility of  a  cure  without  the  division  of  ligaments, 
of  part  of  the  plantar  fascia;  and  even  without  some 
operation  on  the  bones. 


CHAPTER  VI 

TREATMENT  OF  CONGENITAL  CLUB-FOOT 
(TALIPES  EQUINO-VARUS) 

No  time  should  be  lost  in  beginning  treatment.  Some 
emphasize  this  rule  by  insisting  that  treatment  be  begun 
the  day  of  birth,  "at  the  hour  of  birth"  (Willard). 
Others  postpone  giving  any  attention  to  the  deformity 
until  the  baby  is  two  weeks  old.  Delay,  however,  of 
several  months  is  simply  neglect. 

EARLY  TREATMENT 

Early  treatment  consists  of  frequent  gentle  manual 
correction  and  the  employment  of  some  means  of  re- 
taining the  foot  in  an  improved  position.  Frequently 
this  improved  position  will  become  in  a  few  weeks  the 
fully  corrected  or  even  an  over-corrected  position.  The 
degree  of  the  deformity  and  the  resistance  met  in  over- 
coming it,  should  determine  the  method  to  be  followed. 
Cases  which,  from  the  beginning,  show  a  marked  im- 
provement from  manipulation  and  simple  bandaging  may 
be  thus  treated  as  long  as  improvement  continues.  As 
soon,  however,  as  improvement  becomes  arrested,  greater 
care  must  be  given  to  the  retention  apparatus.  The  foot 
must  be  held  at  all  times  in  the  best  possible  position; 

125 


126  DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

only  in  this  way  can  progress  be  made.  If  the  apparatus 
used  is  a  removable  one  and  if  massage  and  movements 
at  the  joints  are  practiced,  care  must  be  exercised  to  pre- 
vent the  assuming  of  the  deformed  position,  even  for  a 
moment,  while  the  apparatus  is  off.  The  apparatus 
should  not  be  removed  from  both  feet  at  the  same  time : 
one  only  is  removed,  that  foot  massaged  and  exercised 
and  the  apparatus  re-applied,  and  then  the  same  treat- 
ment is  given  to  the  other  foot. 

Manipulation. — "  Of  all  curative  measures,  ma- 
nipulation stands  first  "  (Willard).  Bearing  in  mind  the 
three  axes  of  the  foot  through  which  the  deformity 
occurs,  gentle  momentary  attempts  are  made  to  turn 
the  foot  on  these  axes  toward  the  normal  position.  The 
leg  is  held  firmly  about  the  ankle  with  one  hand,  the  right 
leg  with  the  right  hand;  and  the  forefoot  grasped  with 
the  other  hand  in  such  a  way  that  the  plantar  surface 
rests  in  the  palm  of  the  hand,  the  fingers  encircling  the 
outer  border,  the  thumb  the  inner;  and  movements  are 
made  to  overcome  the  adduction  and  inversion.  By 
holding  the  first  and  second  fingers  of  the  hand  holding 
the  leg, —  the  right  hand  if  the  right  leg  is  being  manipu- 
lated,—  against  the  outer  surface  of  the  os  calcis,  the 
surgeon  can  concentrate  his  force  in  attacking  the  adduc- 
tion. If  the  OS  calcis  is  not  held,  the  force  will  be 
exerted  toward  correcting  both  the  adduction  and  the 
inversion.  By  placing  the  palm  of  the  hand,  the  right 
in  treating  the  right  foot,  against  the  plantar  surface  in 
such  a  way  that  the  heel  rests  in  and  is  grasped  by  the 


TREATMENT   OF    CONGENITAL    CLUB-FOOT  12/ 

fingers,  the  toes  resting  against  the  base  of  the  palm,  he 
may  direct  all  his  force  to  obtaining  movement  through 
the  antero-posterior  axis,  overcoming  inversion,  and  also 
through  the  transverse  axis  at  the  ankle,  overcoming 
equinus.  The  deformity  of  equinus,  however,  demands 
little  attention  until  the  others,  the  adduction  and  the  in- 


FiG.  44.    Manipulation  of  Congenital  Club-Foot 
Position  of  the  hand  and  the  direction  of  the  force  in  overcoming 
inversion  and  equinus. 

version,  have  been  practically  cured.  There  are  two 
reasons  for  this:  the  tight  heel-cord  gives  an  excellent 
fulcrum  against  which  the  force  used  in  correcting  the 
other  deformities  may  be  exerted  and  without  which  it 
is  difficult  to  obtain  a  fulcrum;  and  the  equinus  seldom 
offers  much  difficulty  of  itself,  even  if  neglected  for  some 


128         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

months.  Furthermore,  when  walking  is  begun,  the 
weight  of  the  body  usually  does  much  to  correct  the 
equinus,  and  should  this  not  be  all  that  is  necessary, 
division  of  the  tendo  Achillis  is  a  simple  and  satisfactory 
procedure. 

The  manipulative  treatment  should  not  consist  of  a 
seance  of  yelling  and  screaming.  It  is  not  necessary 
and  it  far  from  increases  the  confidence  of  the  mother. 
The  object  is  not  to  accomplish  much  in  any  one  treat- 
ment, only  by  frequent  treatments.  Manipulation  is  too 
often  practiced  as  though  it  had  some  occult  power  and  is 
sometimes  prescribed  in  a  more  or  less  careless  way.  The 
administration  of  manipulation  is  by  no  means  an  indiffer- 
ent matter.  The  regularity  of  treatments,  the  time  given 
to  each  treatment,  and  the  detail  of  each  treatment  are 
all  of  vital  importance  if  one  would  meet  with  success. 
If  manipulation  is  to  form  an  important  part  of  treat- 
ment, and  it  should  in  every  case,  it  is  absolutely  neces- 
sary to  take  the  time  and  to  exert  the  patience  to  teach 
some  member  of  the  household  how  to  do  it.  It  seems 
to  me  that  the  success  of  the  teaching  depends  more  upon 
the  physician  than  upon  the  intelHgence  of  the  mother  or 
nurse,  who  can  generally  be  counted  on  to  carry  out 
faithfully  the  instructions  as  taught.  The  exact  hours 
of  the  day  that  the  manipulations  are  to  be  performed 
should  be  prescribed  as  carefully  as  are  the  hours  for 
nursing  an  infant  or  the  administration  of  a  medicine. 
The  number  of  times  that  each  manipulation  is  to  be 
done  should  be  designated;  as  twenty  of  these  move- 


TREATMENT   OF    CONGENITAL    CLUB-FOOT  1 29 

ments,  twenty  of  these  others,  and  ten  of  these.  The 
massage  should  be  prescribed  by  time ;  as  rubbing  the  leg 
for  one  minute  and  the  foot  for  one  minute,  by  the  clock. 
Then  the  re-application  of  the  apparatus  must  be  taught 
in  the  minutest  detail.  The  laity  are  now  so  accustomed 
to  being  taught  details,  as  for  instance,  regarding  the 
temperature  of  the  bath,  the  preparing  of  the  bottle,  etc., 
that  the  statement  that  they  are  unable  to  follow  instruc- 
tions as  to  manipulations  of  a  deformed  foot  or  of  the 
application  of  a  brace,  is,  it  might  seem,  a  reflection 
upon  the  physician  as  an  instructor. 

For  the  first  few  weeks  the  manipulations  should  be 
done  by  the  physician  as  frequently  as  possible,  if  not 
daily,  at  least  several  times  a  week.  Subsequently  the 
physician  need  see  the  patient  but  once  a  week,  and,  if 
all  is  going  well,  the  time  may  be  increased  to  two  weeks. 
The  resistance  which  the  deformity  shows  and  the  care 
with  which  his  instructions  are  carried  out,  must  be  the 
determining  factors  in  deciding  on  the  frequency  of  the 
visits.  At  each  visit  the  mother  or  nurse  should  go 
through  with  the  treatment  exactly  as  she  is  accustomed 
to  do  it  at  home.  The  physician  is  thus  able  to  correct 
any  little  mistakes.  Otherwise  errors  in  treatment  or  in 
the  application  of  the  brace  are  likely  to  creep  into  the 
procedures.  If  there  comes  a  halt  in  the  progress  of  the 
improvement,  then  some  change  must  be  made  in  treat- 
ment. The  manipulations  are  not  being  performed  regu- 
larly and  exactly,  or  the  brace  is  not  doing  the  work  for 
which  it  was  designed.     If  the  fault  can  not  be  located 


.130         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

and  remedied,  the  brace  had  better  be  discarded  and 
plaster-of-Paris  substituted.  Some  surgeons  are  unable 
to  fit  a  brace  so  that  it  will  be  efficient,  and  if  they  are 
adepts  at  applying  a  plaster-of-Paris  bandage  they  had 
much  better  not  attempt  the  use  of  a  brace  at  all. 

Cases  come  to  us  all  which  are  more  fitted  for  treat- 
ment with  plaster  than  with  a  brace,  and  it  therefore 
should  be  within  our  range  of  skill  to  use  whatever  a 
case  may  demand,  just  as  we  must  be  ready  to  operate 
when  an  operation  is  necessary. 

Apparatus. —  Muslin  Bandage.  In  some  few  cases 
a  simple  muslin  bandage  may  be  used.  It  should  be 
one  and  one-half  inches  wide  for  an  infant  and  about 
three  yards  long.  This  is  applied  with  a  few  turns  about 
the  foot,  close  to  the  toes,  and  is  then  extended  up  the 
leg.  It  should  be  applied  so  as  to  unroll  the  foot ;  begin- 
ning at  the  outer  border  of  the  foot,  it  should  pass  over 
the  dorsum  to  the  inner  border  and  thence  across  the 
plantar  surface,  these  turns  being  repeated  three  times; 
then  the  bandage  should  be  carried  up  the  outer  side  of 
the  leg  and  traction  made,  the  foot  being  pulled  into  a 
position  as  nearly  approaching  valgus  as  may  be,  and 
the  position  so  held  with  one  hand  while  with  the  other 
the  bandage  is  secured  by  a  few  turns  about  the  leg  and 
then  continued  down  to  the  toes  in  a  spiral  fashion. 
Though  this  bandage  may  be  of  some  service  as  a  tem- 
porary measure  while  a  brace  is  being  constructed,  not 
much  can  be  expected  from  it.  The  forefoot  slips  around 
in  the  turns  about  it  and  even  if  much  force  is  at  first 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  I3I 

obtained  toward  correcting  the  varus,  it  will  soon  be 
lost  by  the  slipping  of  the  bandage  down  the  leg. 

Adhesive  Plaster. —  A  strip  of  adhesive  plaster  ap- 
plied in  the  same  way  will  be  much  more  effective.  After 
a  few  turns  about  the  forefoot  with  a  strip  three-fourths 
of  an  inch  wide,  it  is  carried  up  the  outer  side  of  the 
leg  and,  while  the  foot  is  held  in  the  best  position  attain- 
able, it  is  made  to  adhere  to  the  upper  third  and  is  further 
secured  by  a  strip  encircling  the  calf.  If  a  fairly  good 
position  has  been  obtained,  the  lower  third  or  so  of  the 
piece  extending  up  the  leg  will  stand  away  from  the  skin. 
A  cotton  bandage  is  applied  from  the  toes  to  the  knee. 
With  this  adhesive  plaster  strapping  some  manipulations 
may  be  performed  without  its  removal  and  the  muscles 
and  the  skin  other  than  that  covered  by  the  plaster  may 
be  massaged  and  kept  clean  and  healthy.  After  the 
plaster  is  applied  to  the  forefoot  and  before  the  leg  strip 
is  secured,  care  must  be  taken  that  with  the  foot  held 
over  in  valgus  the  edge  of  the  plaster  does  not  cut  into 
the  skin,  as  may  easily  happen.  As  with  older  children 
and  with  adults,  some  babies'  skin  is  easily  irritated  by 
the  plaster  and  it  will  not  be  tolerated.  In  these  cases 
a  cotton  bandage  must  be  first  applied  and  the  adhesive 
outside  of  that;  but  this  method  is  not  at  all  satisfactory 
as  the  plaster  is  robbed  of  much  of  its  usefulness. 

Braces. —  Perhaps  the  simplest  brace  is  the  one  de- 
vised by  Judson.  It  consists  of  a  piece  of  brass  or  other 
metal,  about  four  inches  long  and  one-half  an  inch  wide, 
with  cross  pieces   riveted  at  either  end.     These   cross 


132 


DISEASES   AND   DEFORMITIES    OF   THE    FOOT 


pieces  are  very  light  and  easily  molded  with  the  hand 
to  any  desirable  shape.  One  cross  piece  is  to  fit  about 
the  calf  of  the  leg  and  is  about  two  inches  long  and  three- 


Fig.  45 


|3 


CO 


Fig.  49 


Fig.  52 


Fig.  so  Fig.  SI 

The  Judson  Club-Foot  Brace 

In  Fig.  45  the  arrows  indicate  the  directions  in  which  pressure  is 
to  be  obtained  and  the  points  of  appUcation  of  these  forces  to  the 
deformed  foot  are  shown  in  Fig.  46. 

Fig.  47  illustrates  the  brace  and  Fig.  48  its  application. 

As  improvement  is  obtained  in  straightening  the  deformity,  the 
brace  is  straightened  as  in  Fig.  49  and  applied  as  in  Fig.  50. 

Finally  the  brace  is  bent  into  the  opposite  curve  to  that  in  which  it 
was  first  applied,  Fig.  51,  and  when  secured  to  the  foot,  Fig.  52, 
produces  an  over-correction. 

quarters  of  an  inch  wide.  The  other  is  to  fit  about  the 
forefoot  and  is  one  and  a  half  inches  long  and  one-half 
an  inch  wide.  The  length  of  the  calf-band  and  the  foot- 
band  should  be  such  as  to  encircle  two-thirds  of  the  calf 


TREATMENT   OF   CONGENITAL   CLUB-FOOT  1 33 

and  foot  respectively,  and  therefore  the  above  measure- 
ments are  only  approximate.  Each  is  riveted  by  one 
rivet  so  that  it  may  be  turned  to  lay  flat  against  the  skin, 
regardless  of  the  direction  of  the  long  bar,  and  may  not 
cut  into  the  tissues.  The  completed  apparatus  is  covered 
with  chamois  or  other  soft  material.  The  long  bar  is 
now  curved  with  wrenches  so  that  it  will  lie  flat  along 
the  leg  from  the  inner  side  of  the  calf  to  the  inner  border 
of  the  foot  at  about  the  center  of  the  first  metatarsal, 
with  the  foot  in  its  best  possible  position.  On  account 
of  the  equinus  deformity,  this  will  be  about  a  straight 
line.  That  portion  opposite  the  ankle  and  the  medio- 
tarsal  joint  is  then  bent  so  as  to  lie  about  one-half  an 
inch  away  from  the  ankle  and  foot.  Small  strips  of 
adhesive  plaster  are  made  to  complete  the  circumference 
of  the  bands  about  the  calf  and  forefoot,  and  a  third 
strip  draws  the  ankle  close  to  the  upright  bar. 

This  apparatus  is  easily  removable  and  applicable,  and 
is  so  simple  in  its  construction  that  it  can  readily  be 
made  by  any  surgeon.  The  material  for  making  it  can 
be  found  in  any  village  or  on  any  farm.  Any  piece  of 
tin  used  in  several  thicknesses  to  give  strength  and  riveted 
together  will  answer  the  purpose ;  and  any  soft  cloth  may 
be  used  to  cover  the  brace.  Two  monkey  wrenches 
screwed  down  to  grasp  the  long  bar  on  the  flat,  will  give 
ready  means  for  shaping  the  brace  as  desired. 

Felt  Splint. —  Poroplastic  felt  may  be  shaped  into  a 
retention  splint  and  acts  very  well  if  properly  constructed. 
However,  it  can  not  be  altered  to  fit  improved  positions, 


134         DISEASES   AND    DEFORMITIES    OF   THE   FOOT 

is  not  always  readily  obtainable,  and  requires  more  ex- 
perience in  making  than  do  most  braces.  It  usually  needs 
some  reenforcement,  and  great  care  is  demanded  so  that 
creases  on  its  inner  side  do  not  cause  excoriations.  To 
make  it :  For  a  pattern,  take  a  piece  of  paper  long 
enough  to  reach  from  the  calf  at  a  point  opposite  the 
tibial  tubercle  to  the  end  of  the  great  toe  and  wide  enough 


Fig.  53.    The  Single  Steel  Bar  Brace 
This  brace  is  suitable  for  use  in  early  cases.    The  deformity  of 
adduction  is  the  one  which  yields  the  most  readily  to  its  application. 
The  bar,  properly  padded,  is  secured  to  the  outer  bordet-  of  the  foot. 

to  reach  half  way  around  the  leg  and  foot.  A  wedge- 
shaped  piece  is  cut  out  of  each  side  opposite  the  ankle, 
and  any  trimming  necessary  is  done.  The  pattern  is 
then  laid  upon  a  piece  of  felt  and  the  felt  cut  to  con- 
form with  it.  The  felt  may  be  softened  in  a  number 
of  ways;  — ^by  placing  it  in  hot  water,  125  F.,  until  it  is 
soft,  when  it  is  rapidly  dried  between  towels  and  applied 
and  molded  to  the  leg  and  foot, —  the  foot,  of  course. 


TREATMENT    OF    CONGENITAL    CLUB-FOOT 


135 


being  held  in  the  best  possible  position, —  and  a  cotton 
bandage  smoothly  and  firmly  applied.  In  a  few  minutes 
the  felt  will  be  hardened  and  it  is  then  removed  and 


Fig.  54.  The  Single  Steel  Bar  Brace 
After  being  secured  to  the  foot,  it  is  brought  up  parallel  to  the 
leg,  but  if  not  bent  with  wrenches  so  as  to  fit  the  angle  which  the 
best  possible  position  of  the  foot  forms  with  the  leg,  it  will  not  be 
efficient.  The  upper  end  of  the  bar  will  either  stand  away  from 
the  leg,  as  in  the  illustration,  and  as  would  happen  at  the  beginning 
of  treatment,  or  it  will  come  into  contact  with  the  leg  before  all 
possible  correction  is  procured,  as  would  happen  when  over-correc- 
tion was  being  attained. 

further  trimmed  and  any  wrinkles  cut  out  of  its  inner 
surface.  It  may  be  secured  in  position  by  adhesive  straps 
or  by  a  bandage.  If  straps  are  riveted  to  it  at  its  upper 
end,  at  the  ankle  and  at  the  forefoot,  it  will  be  somewhat 


136 


DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


easier  to  remove  and  to  apply.  Chloroform  may  be  used 
as  a  softening  agent  and  is  especially  useful  if  it  is  de- 
sired to  re-soften  any  particular  places. 

Wood  Splint. —  A  very  effective  splint,  especially  for 
the  first  few  weeks  of  treatment,  is  a  straight  piece  of 


Fig.  55.    The  Single  Steel  Bar  Brace 
_  The  bar  has  been  curved  so  as  to  securely  hold  all  of  the  correc- 
tion which  it  is  possible  to  obtain  with  its  leverage  action,  and  at 
the  same  time  to  lie  snugly  against  the  upper  part  of  the  leg. 

wood,  reaching  from  the  knee  to  three  inches  below  the 
toes,  about  an  inch  wide  and  a  quarter  of  an  inch  thick. 
It  is  well  padded  and  bound  to  the  foot  by  a  cotton  band- 
age. A  small  pad  is  placed  opposite  the  ankle  and  the 
upper  extremity  of  the  splint  drawn  over  to  the  leg  and 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 37 

bound  by  continuing  the  bandaging-  up  the  leg.  The  pad 
at  the  ankle  acts  as  a  fulcrum  and  will  therefore  influence 
the  amount  of  the  correction  obtained.  Too  much  pad- 
ding must  not  be  used  at  first,  but  it  can  be  gradually 
increased  at  successive  dressings.  If  a  piece  of  metal  is 
used  instead  of  the  wood,  its  efficiency  can  be  increased 
by  turning  the  bar  with  wrenches  as  described  in  the 
Judson  brace. 

Plaster-of-Paris.  —  The  plaster-of -Paris  dressing  is 
used  in  the  following  manner :  Strips  of  cotton  wadding 
one  and  one-half  inches  long  and  the  size  of  a  lead  pencil 
are  placed  between  the  toes,  allowing  the  ends  to  extend 
an  equal  distance  up  the  dorsum  and  down  the  plantar 
surface  of  the  foot.  Two  strips  of  adhesive  plaster  five 
inches  long  and  three-eighths  of  an  inch  wide  are  placed 
along  the  inner  and  outer  sides  of  the  leg  in  such  a  way 
that  the  upper  half  of  each  adheres  to  the  leg  while  the 
lower  half  extends  below  the  foot  and  may  be  turned  up 
and  incorporated  into  the  plaster-of-Paris  bandage  and 
so  prevent  its  slipping  down  and  off  the  foot.  A  flannel 
or  cotton  bandage  is  next  applied.  This  should  be  one 
and  one-half  inches  wide.  Beginning  at  the  toes  it  is 
wound  around  the  foot  and  leg  in  such  a  direction  as  to 
tend  to  unroll  the  foot.  It  is  put  on  in  circular  turns 
and  should  lie  very  smoothly,  without  wrinkles,  and 
should  not  be  drawn  tightly  in  any  turn.  The  plaster 
bandage  is  now  applied.  It  should  be  of  the  same  width 
as  the  cotton  bandage  and  should  be  applied  in  the  same 
way  as  to  direction  and  as  to  care  in  not  causing  con- 


138         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

strictions  at  any  turn  and  in  not  having  any  wrinkles. 
As  each  turn  is  applied  it  is  thoroughly  rubbed  into  the 
one  preceding,  as  in  this  way  the  strength  of  the  dressing 
is  greatly  increased.  After  the  first  two  layers  are  put 
on,  the  adhesive  plaster  strips  are  turned  up  and  incorpo- 
rated in  the  plaster-of-Paris.  During  the  entire  pro- 
cedure it  is  essential  that  the  foot  be  retained  in  the  best 
position ;  corrected  or  even  over-corrected.  The  office  of 
the  plaster-of-Paris  is  to  retain  the  foot  in  the  position 
in  which  the  plaster  is  applied.  That  is  all.  Of  itself 
it  does  not  cause  any  further  correction.  After  the  plas- 
ter is  applied  no  further  correction  should  be  attempted. 
There  is  temptation  still  further  to  improve  the  position 
while  the  plaster  is  hardening,  but  this  must  not  be  done 
as  there  are  great  probabilities  that  the  movement  will 
cause  folds  and  creases  and  thereby  injure  the  skin. 
With  a  little  experience  a  surgeon  is  able  to  hold  an 
infant's  foot  with  one  hand  while  with  the  other  hand 
he  rolls  the  plaster  bandage  about  the  leg  and  foot,  his 
assistant  holding  the  bandage  as  he  passes  his  hand  from 
one  side  of  the  leg  to  the  other. 

This  dressing  should  be  removed  once  in  two  weeks; 
that  on  one  foot  being  changed  one  week  and  that  on  the 
other  the  next  week.  In  this  way  the  time  of  each  visit 
is  but  a  few  minutes,  a  valuable  point  in  the  treatment 
of  babies,  and  it  also  allows  for  the  observation  of  the 
plaster  applied  the  week  previously. 

Points  to  be  observed  in  the  application  of  plaster-of- 
Paris  in  these  cases  are  as  follows :     Do  not  use  too  much 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 39 

padding;  do  not  manipulate  so  severely  as  to  cause  any- 
subsequent  swelling,  which  would  make  a  close  fit  at  the 
time  the  plaster  is  applied  become  a  tight  one  later.  The 
points  of  the  greatest  pressure  will  be  on  the  inner  side 
of  the  forefoot  and  heel  and  on  the  outer  side  of  the 
medio-tarsal  joint  and  over  the  external  malleolus.  Un- 
roll the  plaster  bandage  smoothly,  laying  it  on  rather 
than  binding  it  on.  Hold  the  foot  steadily  in  the  best 
attainable  position,  from  the  beginning  until  the  operation 
is  finished.  Three  to  five  layers  of  the  plaster  bandage 
are  all  that  is  necessary  providing  the  layers  are  well 
incorporated,  rubbed.  Compress  the  forefoot  between 
the  hands,  in  a  dorsal-plantar  direction,  so  as  to  assure 
sufficient  room  for  the  toes.  Mold  the  plaster  carefully 
over  the  instep;  this  will  be  of  great  assistance  in  pre- 
venting the  dressing  from  slipping  down  and  of¥  the  foot. 
One  of  the  objections  to  a  bandage  which  is  thicker  than 
it  need  be,  is  that  on  account  of  its  weight  it  is  more 
easily  kicked  off  by  the  baby. 

Willard's  Shoe. —  Willard  used  a  simple  arrange- 
ment whereby  a  correcting  force  can  be  continuously 
exerted.  A  close  fitting  leather  shoe  lacing  down  to  the 
toe  has  its  shank  removed  or  replaced  by  soft  leather,  so 
that  free  movement  may  be  had  between  the  fore  and 
hind  part  of  the  shoe.  A  stirrup-iron  reaching  up  to  the 
knee  is  secured  to  the  outer  side  of  the  shoe.  A  stout 
piece  of  catgut  is  attached  to  the  shoe  at  a  spot  to  the 
outer  side  of  the  little  toe  and  then  threaded  through  an 
eyelet  on  a  short  piece  of  steel  extending  forward  and 


140         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

outward  from  the  bend  of  the  stirrup,  and  is  secured  to 
a  piece  of  elastic  which  is  fastened  by  its  other  end  to  a 
buckle  or  a  button  on  the  upright  at  a  point  opposite  the 
tibial  tubercle.  The  eyelet  through  which  the  catgut 
passes  should  be  so  placed  that  the  vertical  axis  of  move- 
ment of  the  medio-tarsal  joint  shall  have  the  same  radius 
from  it  as  has  the  point  of  attachment  of  the  catgut  to 
the  shoe.  Willard  strongly  advocated  this  apparatus  and 
without  experience  in  its  use  criticism  seems  ill-advised, 
but  it  scarcely  appeals  to  me  except  for  use  in  very  mild 
cases. 

Taylor's  Brace. —  The  Taylor  club-foot  brace  is  a 
very  efficient  apparatus  after  the  baby  is  a  few  months 
old.  It  consists  of  an  inside  leg-bar  with  a  calf  band, 
jointed  below  to  a  foot-piece.  The  foot-piece  has  a  sole 
plate  with  a  flange  curving  up  over  the  first  metatarsal 
and  another  flange  at  the  inner  side  of  the  heel.  On  the 
outer  side,  opposite  the  heel,  is  a  small  extension  with  a 
slot  through  which  is  passed  a  strap  which  goes  over  the 
ankle  and  into  another  slot  on  the  heel-flange,  to  hold 
the  heel  down  against  the  foot-plate.  The  joint  at  the 
ankle  permits  one  to  fit  the  brace  to  any  degree  of 
equinus.  By  bending  the  upright  leg-bar  any  degree  of 
eversion  may  be  obtained.  The  bending  upward  and 
outward  of  the  toe-flange,  or  the  interposition  of  pieces 
of  felt,  will  increase  the  abduction  of  the  forefoot.  This 
form  of  brace  may  be  used  after  the  child  begins  to  walk, 
and  will  be  found  to  meet  every  indication  if  it  is  properly 
designed  and  is  kept  properly  fitted.     When  used  as  an 


TREATMENT    OF    CONGENITAL    CLUB-FOOT 


141 


ambulatory  apparatus,  a  piece  of  wood,  made  wedge- 
shaped  so  that  its  inner  edge  will  be  from  one  to  two 
inches  higher  than  its  outer  edge,  thus  acting  as  a  strong 


STITZELi  BUECHEFf. 

illliitlKUIHlKliimilllliHlllHtimKlHiKHuniniUi 


Fig.  56.  The  Taylor  Club-Foot  Brace 
This  illustrates  a  design  somewhat  modified  from  the  original,  but 
the  principles  of  mechano-therapeutics  upon  which  it  is  constructed 
are  essentially  the  same.  The  peg-stop  at  the  joint  had  better  be  a 
screw  and  several  holes  should  be  tapped  so  that  by  changing 
the  position  of  the  screw  the  foot-piece  can  be  adjusted  to  fit  the 
amount  of  equinus  present  at  the  time  of  application  and  can  readily 
be  altered  as  dorsal-flexion  is  increased.  With  the  inside  flange  ex- 
tending from  the  toe  to  the  heel,  the  flange  itself  cannot  be  changed 
so  as  to  alter  the  amount  of  abduction  obtainable ;  abduction  must 
be  increased  by  inserting  felt  or  other  material  between  the  flange 
and  the  forefoot. 


everter  of  the  foot,  may  be  riveted  to  the  under  side  of 
the  foot-plate. 

To  design  the  Taylor  brace,  a  piece  of  modeling  card- 
board is  desirable,  although  any  other  easily  cut  and 
easily  molded  material   will   answer  the  purpose.     An 


142 


DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


outline  of  the  bottom  of  the  foot  is  first  traced  upon  the 
cardboard  and  then  with  the  pencil  the  flanges  and  the 
extension  for  the  ankle  strap  are  drawn  as  they  would 
appear  if  flattened  out  to  the  plane  of  the  foot-plate. 
This  tracing  is  then  cut  out,  the  flanges  bent  up,  and 


Fig.  57.  Taylor  Club-Foot  Brace 
The  brace  is  applied  by  first  securing  the  foot-piece  to  the  foot  in 
its  deformed  position.  The  leg-bar  is  then  brought  across  the  leg, 
everting  the  foot,  and  backward  to  the  line  of  the  leg,  and  the  band 
slipped  about  the  calf,  which  corrects  the  equinus  deformity.  The 
flange  on  the  inner  side  holds  the  foot  in  abduction. 

the  model  tried  on  the  foot.  It  is  essential  that  the  foot 
be  held  in  the  best  position  while  the  fitting  is  being  done. 
Alterations  are  marked  and  the  changes  made,  and  these 
repeated  until  the  model  fits  evenly  and  snugly.  Then 
the  leg-bar  is  cut  out,  fitted,  and  marked  for  the  joint 
with  the  foot-piece.     A  model  of  the  calf -band  is  made 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 43 

in  the  same  way.  By  making  deep  slots  in  the  forefoot 
flange,  extending  from  the  edge  well  down  into  the  sole- 
plate,  one  may  more  easily  alter  the  completed  apparatus 
as  the  adduction  is  overcome.  With  this  model,  any 
worker  in  metal,  such  as  a  tinsmith,  can  make  a  perfectly 
satisfactory  brace.  A  leather  worker,  such  as  a  shoe- 
maker, can  line  the  brace  as  desired  and  make  the  straps. 
Deformity  in  the  Long  Bones. —  It  is  seldom  neces- 
sary to  extend  above  the  knee  whatever  apparatus  is 
used  to  correct  deformity  in  the  long  bones.  Yet  cases 
will  be  met  with  in  which  the  foot  seems  to  be  in  a  good 
position  in  its  relation  to  the  leg  but  persists  in  retaining 
a  position  of  inward  rotation,  so  that  the  toes  are  pointed 
inward.  This  rotation  may  be  confined  to  a  rotation  at 
the  knee  or  to  an  inward  twist  of  the  tibia  or  of  the  femur 
or  it  may  be  due  to  a  posterior  curving  of  the  neck  of 
the  femur.  To  determine  this  matter,  the  foot  is  placed 
in  its  normal  position  with  relation  to  the  vertical  plane 
of  the  body;  and  the  direction  of  the  external  face  of 
the  great  trochanter,  to  the  position  of  the  external 
epicondyle,  and  the  location  of  the  patella  determined ;  or 
the  foot  may  be  left  in  its  apparently  deformed  position 
and  the  relations  of  these  anatomical  points  then  ascer- 
tained. If  the  vertical  plane  containing  the  external 
border  of  the  patella  is  outside  of  the  great  toe,  the  foot 
being  dorsal  flexed  to  a  right  angle  and  the  knee  ex- 
tended, then  a  twist  exists  in  the  shafts  of  the  bones  of 
the  leg.  According  to  J.  K.  Murphy  this  twist  in  the 
tibia  and  fibula  exists  in  a  large  proportion  of  cases. 


.144         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

Those  due  to  a  twist  in  the  femoral  shaft  or  neck  are 
less  frequent.  Laxity  of  the  knee  ligaments  is  more 
likely  to  prove  to  be  a  confusing  factor  in  early  child- 
hood than  in  infancy. 

Until  the  child  begins  to  walk,  no  other  treatment  than 
manipulation  is  necessary  for  these  causes  of  inward  ro- 
tation. The  manipulation  should  consist  of  untwisting 
movements  performed  at  the  time  of  the  other  manipu- 
lations. Of  course  if  there  is  extra  lateral  movement  at 
the  knee  joint  no  exercises  are  used :  usually  nothing  need 
be  done,  but  the  ligamentous  laxity  can  be  improved  by 
immobilizing  the  knee  joint  during  the  day  when  the 
child  is  most  active.  Whatever  apparatus  is  being  used 
to  treat  the  foot  can  be  carried  up  so  as  to  include  the 
knee,  as  is  recommended  by  some  orthopedic  surgeons 
in  every  case  of  club-foot;  but  we  would  remind  the 
reader  that  the  less  immobilization  required  the  better  is 
the  development,  a  most  important  consideration  at  all 
times  of  life,  but  of  especial  importance  during  infancy 
and  youth. 

After  the  child  begins  to  walk,  it  may  be  best  to  cor- 
rect any  inward  rotation  by  continuing  the  leg-bar  of  the 
brace  up  to  a  pelvic  band.  It  will  be  useless  to  make  a 
brace  to  include  only  the  thigh.  Free  joints  should  be 
had  at  the  knee  and  hip. 

Osteotomy  or  osteoclasis  should  not  be  performed 
while  the  bones  are  yet  soft ;  after  the  bones  have  har- 
dened these  operations  may  be  necessary. 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 45 

Therapeutics  of  Early  Treatment. —  Impatience  for 
results  should  not  lead  one  to  attempt  too  great  a  cor- 
rection within  the  first  few  weeks.  It  is  well  to  remem- 
ber that  no  brace  or  plaster-of-Paris  bandage  is  actively 
reducing  the  deformity  while  it  is  in  place.  They  are 
retention  apparatuses  only.  If  the  foot  is  not  being  used 
for  support,  there  is  no  influence  exerted  on  any  of  the 
structures  except  in  a  passive  way.  By  holding  the  foot 
in  a  position  which  causes  a  slack  in  the  muscles  and 
ligaments,  which  are  abnormally  long  in  the  deformed 
foot,  these  apparatuses  cause  nature  to  shorten  those 
structures  and  thus  are  a  powerful  means  of  bringing 
about  a  cure;  but  they  are  not  re-shaping  bones  nor 
exerting  a  corrective  force  while  in  situ. 

The  object  to  be  aimed  at  in  any  form  of  treatment 
is  an  exaggerated  abduction  and  eversion.  There  is  no 
danger  of  this  over-correction  becoming  itself  a  deform- 
ity. The  so-called  relapses  are  much  more  likely  to  occur 
when  the  correction  has  been  limited  to  a  restoration  of 
the  foot  to  its  normal  position,  because  this  apparent 
correction  is,  in  all  probability,  limited  to  the  soft  parts 
and  is  hiding  deformities  of  the  bones  which  per- 
sist and  which,  upon  the  foot's  assuming  its  functions, 
become  aggravated.  If  this  over-correction  can  be  ob- 
tained and  maintained  until  the  child  begins  to  walk,  the 
best  possible  result  may  be  expected.  The  equinus  posi- 
tion need  not  be  fully  corrected  before  the  end  of  at  least 
the  tenth  month  (Willard). 


146  DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

TREATMENT  WHEN  THE  CHILD  BEGINS  TO  STAND 

When  the  child  begins  to  stand,  a  new  element  enters 
into  consideration.  The  weight  of  the  body  may  be 
used  as  a  powerful  means  of  aiding  correction  and,  on 
the  other  hand,  if  it  is  not  properly  directed,  this  very 
force  may' make  the  condition  much  worse.  The  mus- 
cles, ligaments,  and  bones  are  all  actively  used  in  main- 
taining the  upright  position  and,  if  they  are  employed 
as  in  the  normal  foot,  they  will  tend  to  become  normal 
in  strength,  length,  and  shape.  So  important  is  the 
normal  use  of  the  foot  in  overcoming  these  deformities 
that  some  surgeons  reserve  their  most  active  measures 
until  the  age  of  walking  has  been  reached.  Willard,  who 
believed  in  beginning  treatment  at  the  earliest  possible 
opportunity,  said :  "  Walking  in  proper  position  is  a 
mechanical  measure  superior  to  any  apparatus."  Yet 
Kirmisson  believes  it  to  be  indispensable  that  the  child 
should  not  be  allowed  to  make  any  attempts  to  walk 
until  about  the  age  of  twenty  months.  While,  therefore, 
Kirmisson  recognizes  the  potency  of  walking  in  altering 
the  feet,  he  does  not  think  it  advisable,  for  the  ordinary 
surgeon  at  least,  to  attempt  to  direct  this  force  toward 
a  curative  measure.  We  know  of  no  American  ortho- 
pedic surgeon  who  agrees  with  him.  No  amount  of 
massage  or  manipulations  can  be  the  equal  of  even  a 
slight  functional  activity. 

Although  a  plaster-of-Paris  bandage  can  be  applied  so 
as  to  hold  the  foot  in  the  corrected  or  over-corrected  po- 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  I47 

sition  and  the  child  in  standing  and  walking  will  exert 
the  force  of  the  weight  of  the  body  especially  toward 
reshaping  the  bones ;  yet  so  much  more  can  be  obtained 
by  every  normal  activity  which  is  encouraged,  be  it  of 
muscle,  bone,  or  ligament,  that  it  is  advisable  to  use  a 
brace  which  allows  of  more  normal  use  of  the  parts  of 
the  foot  than  can  any  solid  casing.  The  Taylor  brace 
is  a  most  suitable  one  for  this  stage  of  treatment. 


Fig.  58.    Taylor  Club-Foot  Brace  Applied 
This  holds  the  foot  everted  and  abducted  and  at  a  right  angle  to 
the  leg.    A  wedge  piece  of  wood,  extending  the  length  of  the  foot- 
piece,  holds  the  over-correction  when  used  as  an  ambulatory  brace. 

As  soon  as  the  foot  begins  to  assume  its  functions,  the 
lime  salts  are  deposited  much  more  rapidly  in  the  bones 
and  they  become  ossified  in  whatever  shape  they  are 
allowed  to  maintain.  Whereas  up  to  this  time  the  de- 
formity was  due  to  the  soft  structures  more  particularly, 
the  bones  now  assume  a  continuously  increasing  impor- 


148  DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

tance  as  a  factor  in  obstructing  correction  or,  under 
proper  treatment,  in  rendering-  a  cure  permanent. 

It  may  be  well  to  recapitulate  the  most  marked  patho- 
logical changes  in  a  congenital  equino-varus,  untreated 
and  walked  upon.  The  astragalus,  rotated  far  forward, 
in  an  exaggerated  normal  position  as  it  is  during  infancy 
in  this  condition,  will  have  an  increased  growth  of  bone 
on  that  part  of  the  trochlear  surface  which  protrudes 
from  the  mortise,  and  also  an  increased  development  of 
the  peroneal  tubercle.  The  posterior  part  of  the  head 
and  the  adjoining  part  of  the  neck  will  form  the  articular 
surface  for  the  scaphoid.  The  anterior  part  of  the  head, 
left  uncovered  by  the  new  position,  more  posterior  and 
inferior,  assumed  by  the  scaphoid,  may  present  a  ridge 
of  bone  marking  the  anterior  limits  of  the  new  articu- 
lation. As  the  narrowest  part  of  the  trochlear  surface 
is,  in  this  position  of  hyper-extension,  presented  in  the 
tibio-fibular  articulation,  there  may  be  some  slight  rota- 
tion inward  of  the  astragalus,  thus  increasing  the  position 
K)f  adduction.  Various  changes  in  the  neck  have  been 
described  by  different  observers.  The  two  changes  which 
are  of  paramount  importance  to  the  surgeon  are  the 
alteration  of  the  head,  which  may  prevent  reposition  of 
the  scaphoid  to  its  normal  relation  with  this  bone,  and 
the  changes  which  may  positively  interfere  with  the  roll- 
ing back  of  the  trochlear  surface  into  its  mortise. 

Tubby  describes  a  new  non-articular  surface  on  the 
astragalus.  It  is  nearly  quadrilateral;  its  upper  and 
inner  border  is  coterminous  with  the  outer  part  of  the 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  I49 

anterior  and  lower  border  of  the  tibia.  The  upper  and 
outer  border  correspond  with  the  anterior  edge  of  the 
external  malleolus.  The  outer  border  blends  with  the 
prefibular  tubercle  and  the  inner  part  passes  gradually 
into  the  neck  and  head. 

The  OS  calcis,  following  the  position  of  the  astragalus, 
has  its  antero-posterior  axis  directed  forward,  down- 
ward and  inward.  It  may  be  so  far  twisted  inward 
that  its  tuberosity  is  in  contact  with  the  fibula  and  may 
form  a  joint  with  the  external  malleolus.  The  articular 
surface  for  the  cuboid  may  have  an  excrescence  of  bone 
on  its  outer  part,  developed  in  consequence  of  the  cuboid's 
being  partly  dislocated  inward  by  the  adduction  of  the 
forefoot;  and  the  weight  of  the  body  resting  on  this 
surface  and  this  new  bony  growth  may  offer  an  obstruc- 
tion to  the  perfect  replacement  of  the  cuboid.  In  very 
severe  cases  there  may  be  a  twist  of  the  bone  itself  on 
its  long  axis.  The  most  serious  obstacle  offered  by  the 
OS  calcis  to  reduction  of  deformity  is  the  bony  ex- 
crescence on  the  articular  surface  for  the  cuboid. 

The  contractures  of  the  soft  tissues  become  more  firmly 
established  the  longer  treatment  is  postponed  after  birth. 
Those  which  may  have  to  be  divided,  are:  the  tendo 
Achillis,  most  frequently;  the  two  tibials,  next  so;  and 
in  untreated  cases  of  two  years  or  more,  less  frequently 
in  younger  cases,  the  ligaments  comprising  the  capsule 
of  the  astragalo-scaphoid  joint  and  the  plantar  fascia. 
In  markedly  severe  cases  all  the  soft  parts  on  the  inner 
and  plantar  surfaces  may  need  division.     The  posterior 


■  150         DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

ligament  of  the  ankle  joint,  if  it  needs  division,  is  di- 
vided at  the  time  of  tenotomy  of  the  tendo  Achillis,  as 
explained  under  that  operation. 

CONGENITAL  TALIPES    EQUINO-VALGUS 

This  deformity  occurs  in  Whitman's  table,  in  1.7  per 
cent,  of  all  cases  of  congenital  talipes.  The  heel  is  raised 
and  the  foot  can  not  be  brought  to  a  rightangle  with 
the  leg.  The  movements  through  the  other  two  axes, 
the  longitudinal,  sub-astragaloid,  and  the  vertical,  medio- 
tarsal,  are  the  reverse  of  those  found  in  equino-varus. 
The  plantar  surface  turns  outward,  the  outer  border  of 
the  foot  being  raised,  and  the  forefoot  is  abducted. 
Treatment  is  correction  by  manipulation  and  by  appa- 
ratus or  plaster-of-Paris.  The  difficulties  met  are  sel- 
dom difficult  to  overcome. 

CONGENITAL   TALIPES   EQUINUS 

This  is  a  rare  deformity.  Treatment  is  by  manipu- 
lation. Seldom  is  any  brace  or  operation  demanded.  A 
simple  ankle  brace  with  a  right-angle  stop  may  be  applied. 
The  only  operation  that  could  under  any  circumstances 
be  necessary  would  be  division  of  the  tendo  Achillis. 
No  writer  records  a  case  where  it  was  necessary  to  di- 
vide the  posterior  ligament. 

CONGENITAL   TALIPES   VALGUS 

In  frequency  of  occurrence,  this  deformity  stands  next 
to  talipes  equino-varus.     In  all  probability  there  is  some 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  I5I 

elevation  of  the  tuberosity  of  the  os  calcis.  Adams  con- 
sidered this  to  be  the  case.  In  infants  it  is  by  no  means 
easy  to  determine  the  exact  degree  of  dorsal  flexion,  and 
therefore,  what  one  might  term  pure  valgus  another 
might  classify  as  equino-valgus.  However  that  may  be, 
it  is  of  little  importance  as  the  equinus  must,  in  any  case, 
be  slight  and  the  valgus  is  the  pronounced  deformity. 
In  examining  for  this  condition,  it  should  be  borne  in 
mind  that  the  arch  of  the  infant's  foot  is  not  developed 
and  the  normal  flat-foot  must  not  be  allowed  to  lead 
one  astray.  On  the  other  hand,  as  the  normal  foot  at 
this  age  is  held  in  a  position  of  slight  inversion  and  ad- 
duction, the  eversion  and  abduction  are  the  more  notice- 
able. 

Treatment:  If  unaccompanied  by  other  abnormali- 
ties, the  treatment  should  be  along  the  lines  already  laid 
down.  Frequently,  however,  it  is  associated  with  ab- 
sence of  the  fibula.  In  such  cases,  Tubby  found  arthro- 
desis of  the  ankle  joint  necessary  and  not  always 
successful. 

CONGENITAL   TALIPES    VARUS 

In  frequency  this  stands  next  to  pure  valgus.  Tubby 
found  44  cases  in  311  of  congenital  talipes.  Treatment 
is  the  same  as  that  described  for  the  varus  under  equino- 
varus. 

CONGENITAL    TALIPES    CALCANEUS 

This  deformity  in  a  severe  degree,  is  rare.  Upon  an 
attempt  to  plantar  flex  the  foot  the  tendons  on  the  dor- 


152  DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

sum  of  the  foot  may  be  felt  to  tighten.  Three  degrees 
are  described:  that  in  which  the  foot  can  be  plantar 
flexed  to  a  rightangle;  that  in  which  it  can  be  plantar 
flexed  to  an  acute  angle  with  the  leg;  and  that  in  which 
it  lies  almost  parallel  with  the  leg.  There  is  usually 
some  rotation  on  an  antero-posterior  axis  so  that  it  may 
be  called  calcaneo-valgus  or  calcaneo-varus.  Walsham 
states  that  most  of  his  cases  had  the  sole  looking  inward. 
Plantar  flexion  of  the  metatarsal-phalangeal  joints  is 
usually  present.  More  rarely  they  are  fully  extended. 
According  to  Adams,  rigidity  of  the  knee  joint  is  more 
frequently  associated  with  this  deformity  than  with  any 
other  form  of  congenital  talipes. 

The  pathology,  in  slight  degrees,  is  limited  to  a  short- 
ening of  the  anterior  ligaments  and  muscles.  In  more 
severe  cases  there  may  be  elongation  of  the  posterior 
ligaments  and  muscles,  and  there  may  be  some  bony 
changes,  confined  mostly  to  a  prolongation  of  the  articu- 
lar surface  of  the  astragalus  forward.  The  os  calcis 
may  be  almost  vertical.  Hofifa  described  the  cuboid  as 
being  on  almost  the  same  level  as  the  head  of  the  as- 
tragalus. 

Treatment  is  by  manipulation  and  braces.  Division 
of  the  shortened  structures  is  necessary  in  the  severest 
cases. 

CONGENITAL   TALIPES   VALGUS    AND   VARUS 

In  fourteen  cases,  thirteen  were  valgoid  and  one 
was   varoid    (Walsham  and   Hughes).     In  thirty-four 


TREATMENT   OF    CONGENITAL    CLUB-FOOT  1 53 

cases,   twenty-one   were   valgoid   and   two   were  varoid 
(Tubby). 

CONGENITAL    TALIPES    PLANUS 

The  dome  is  developed  only  with  the  development  of 
the  muscles  at  the  time  the  child  begins  to  stand  and 
walk.  If  the  bones  retain  their  infantile  relations,  no 
arch  is  formed  and  a  flat-foot  exists.  A  better  term 
for  this  condition  is  infantile  flat-foot. 

CONGENITAL   TALIPES    CAVUS 

This  is  sometimes  met  with  but  is  very  rare. 

CONGENITAL    TALIPES   VALGO-CAVUS 
CONGENITAL   TALIPES    EQUINO-CAVUS 

Both  of  these  conditions  are  described  but  are  ex- 
tremely rare. 

OPERATIVE    PROCEDURES    IN    THE    TREATMENT    OF     CON- 
GENITAL   CLUB-FOOT 

Wrenching. —  This  consists  of  forcible  manipula- 
tions with  the  patient  under  an  anesthetic.  Usually  the 
hands  are  the  only  instruments  needed,  but  a  wedge- 
shaped  fulcrum  may  oftentimes  be  used  to  advantage, 
and  more  rarely,  a  wrench.  Although  a  break  in  the 
skin  will  occur  only  through  an  accident,  the  preparation 
of  the  feet  as  for  an  open  operation  is  advisable.  When 
the  patient  is  thoroughly  anesthetized,  the  foot  is  grasped 


154  DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

in  the  same  way  as  it  is  for  ordinary  manipulations. 
Whatever  the  deformity  may  be,  the  equinus,  if  such 
exists,  is  to  be  left  to  the  last  attack.  Steady,  strong 
pressure  is  not  the  aim.  Much  more  will  be  gained,  and 
that  with  less  danger  and  in  less  time,  if  the  force  is 
applied  momentarily.  With  the  aid  of  assistants  the 
power  can  be  confined  to  the  desired  joint  and  there  will 
be  no  danger  of  fracturing  bones.  A  foot  which  is  per- 
fectly rigid,  even  with  the  patient  fully  under  the  anes- 
thetic, can  usually  be  rendered  more  or  less  mobile;  but 
perseverance  and  considerable  strength  are  necessary. 
It  may  take  ten  minutes,  or  thirty,  or  forty,  or  even  an 
hour. 

The  object  of  using  an  instrument,  such  as  a  wrench, 
is  to  obtain  more  leverage.  If  the  surgeon  and  his  as- 
sistants have  not  strong  arms  and  hands,  a  wrench  will 
be  of  great  help.  It  should  never  be  employed  simply 
to  gain  time.  It  is  not  free  from  danger,  sucPi  as  severe 
bruising  of  the  soft  parts,  which  may  interfere  with  the 
ultimate  result,  and  the  breaking  of  bones.  Several  pat- 
terns of  wrenches  have  been  made;  such  as  the  Thomas 
wrench,  which  is  the  best  known,  and  the  Myers  wrencK. 
Before  application,  the  foot  is  wrapped  in  a  towel  so  as 
to  lessen  the  friction  between  the  wrench's  jaws  and  the 
skin,  should  there  be  any  slipping;  and  it  is  impossible 
to  avoid  some  slipping.  Rubber  tubing  slipped  over  the 
jaws  is  also  useful  for  this  purpose.  Both  the  tubing 
and  the  towel  or  any  other  sort  of  padding  also  serve 
to  equalize  the  pressure:  as  they  will  spread  out  on  all 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 55 

sides  from  the  prominent  points  of  contact  between  the 
jaws  and  the  foot,  they  will  fill  up  the  depressions  be- 
tween these  points  and  thereby  extend  the  surface  re- 
ceiving the  force.     As  an  illustration  of  the  daring,  or 


Fig.  59.    The  Use  of  a  Wedge 
Overcoming  adduction  by  the  use  of  a  wedge.    There  should  be 
some  padding  between  the  foot  and  the  wedge. 

callousness,  of  some  surgeons  in  the  past,  some  of  the 
devices  for  wrenching  the  foot  are  most  interesting. 

A  wedge-shaped  piece  of  wood,  padded  along  its  apex, 
is  often  used  to  supply  a  fulcrum  in  manual  manipula- 
tion.    It  is  especially  of  service  in  correcting  abduction 


156         DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

or  adduction,  as  it  can  be  placed  in  line  with  the  vertical 
axis  at  the  medio-tarsal  joint. 

After  all  the  correction  possible  has  been  obtained, 
the  question  may  arise  as  to  the  advisability  of  dividing 
some  of  the  contracted  tissues.  It  is  usually  better  to 
postpone  the  use  of  the  knife  until  several  manipulative 
operations  have  been  performed  at  intervals  of  about  six 
weeks;  for  the  improvement  directly  resulting  from 
manipulation  is  increased  by  use,  weight-bearing,  in  the 
improved  position.  The  peculiarities  of  each  particular 
case  must,  however,  determine  this  question.  It  should 
be  remembered  that  if  alterations  in  the  shape  of  the 
bones  is  necessary  for  a  cure,  such  alterations  can  not 
be  expected  to  result  immediately  from  any  re-position 
of  the  parts.  Until  about  the  eighth  year  there  is  no 
doubt  that  the  bones  can  be  influenced  to  change  their 
conformations :  after  that  age  it  is  much  more  difficult, 
but,  I  believe,  quite  possible.  During  manipulation  the 
shape  of  the  bone  is  altered  not  at  all,  unless,  possibly, 
it  might  be  in  infancy.  Manipulation  stretches  the  soft 
structures  so  as  to  permit  the  placing  of  the  bones,  if 
not  too  greatly  altered  in  shape,  in  positions,  in  relation 
to  each  other,  which  are  normal  or  more  nearly  normal. 
If  the  value  of  manipulation  ended  with  the  operation,  it 
would  often  be  worse  than  useless.  The  manipulated 
foot  in  most  cases  of  confirmed  deformity  would  be 
weaker  than  it  was  before  operation  and  would  probably 
be  painful. 

The  object  of  manipulation  is  to  place  the  structures, 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 57 

as  nearly  as  possible,  in  their  normal  positions  and  then 
to  take  advantage  of  those  physiological  laws  which  have 
been  described  by  Wolff  and  by  Davis. 

Wolff's  Law. — "  Every  change  in  the,  form  and 
position  of  the  bones,  or  of  their  function,  is  followed 
by  certain  definite  changes  in  their  internal  architecture, 
and  equally  definite  secondary  alterations  of  their  ex- 
ternal conformation  in  accordance  with  mathematical 
laws." 

If  weight  is  borne  on  the  outer  side  of  a  bone,  for 
instance,  the  lamina  laid  down  in  that  part  will  be  such 
as  to  receive  the  pressure  and  will  differ  from  the  laminae 
laid  down  in  the  other  parts  which  do  not  bear  weight. 
Now  were  the  weight  shifted  so  that  the  function  for- 
merly assumed  by  the  outer  part  of  the  bone  was  borne 
by  the  inner  part,  then  the  style  of  the  internal  archi- 
tecture would  become  exactly  reversed;  the  weight-bear- 
ing part  would  be  altered  to  meet  the  new  function. 
Therefore  it  will  be  understood  that  manipulation  must 
be  followed  by  use  in  the  new  position.  If  the  bones  in 
their  new  relations  to  each  other  are  not  used,  neither 
their  internal  architecture  nor  their  external  configura- 
tion will  be  changed. 

Davis's  "Law. — "  Ligaments,  or  any  soft  tissue, 
when  put  under  even  a  moderate  degree  of  tension,  if 
that  tension  is  unremitting,  will  elongate  by  the  addition 
of  new  material;  on  the  contrary,  when  ligaments,  or 
bther  soft  tissues,  remain  uninterruptedly  in  a  loose  or 
lax  state,  they  will  gradually  shorten,  as  the  effete  ma- 


158  DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

terial  is  removed,  until  they  come  to  maintain  the  same 
relation  to  the  bony  structures  with  which  they  are 
united  that  they  did  before  their  shortening.  Nature 
never  wastes  her  time  and  material  in  maintaining  a 
muscle  or  ligament  at  its  original  length  when  the  dis- 
tance between  their  points  of  origin  and  insertion  is  for 
any  considerable  time,  without  interruption,  shortened." 

These  physiological  laws  are  simply  expressions  of  the 
influence  of  work,  rest,  and  fatigue  on  metabolism  and 
the  resultant  hypertrophy  and  atrophy. 

With  the  bones  of  the  foot  in  an  altered  position  as 
the  result  of  manipulation,  and  the  foot  used  in  weight- 
bearing,  changes  will  occur  in  the  bones,  muscles,  and 
ligaments.  Perfect  functionating,  freedom  of  move- 
ments, can  not  be  allowed  immediately,  as  even  if  the 
contused  condition  of  the  foot,  as  a  result  of  the  manipu- 
lations, did  not  demand  rest,  the  muscles  and  ligaments 
which  have  been  relaxed  and  made  slack  must  be  allowed 
to  shorten,  or  more  strictly  speaking,  be  allowed  to  re- 
build themselves  as  shorter  structures;  else  the  bones 
would  soon  assume  their  former  relations. 

If  the  case  is  one  of  long  standing  and  much  change 
must  take  place  in  the  bones;  absorption  here,  building 
up  there,  and  the  formation  of  new  facets,  then  a  much 
longer  time  will  be  necessary  to  give  stability  to  the  new 
position  than  would  be  demanded  by  a  case  where  the 
anatomical  changes  were  slight  or  were  limited  to  the 
soft  tissues.  It  is  probable  that  an  imperfect  appreci- 
ation of  the  importance  of  this  element  of  time  has  been 


TREATMENT    OF    CONGENITAL    CLUB-FOOT 


159 


the  cause  of  deformed  feet,  apparently  cured,  suffering  a 
relapse,  in  many  such  unfortunate  instances.     The  exact 


Fig.  60.    Relapsed  Congenital  Talipes  Equino  Varus 
If  an  over-corrected  position  is  not  maintained  until,  with  growth, 
all  tendency  to  resumption  of  the  deformity  is  gone,  a  relapse  is 
certain  to  occur. 


time  necessary  for  these  structural  changes  to  take  place 
is  hard  to  determine.     It  doubtless  varies  with  the  age 


l6o  DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

of  the  patient  and  with  the  physiological  activity,  de- 
pending on  constitutional  conditions  and  functional  use, 
as  well  as  with  the  amount  of  structural  changes  neces- 
sary to  effect  a  cure. 

Let  us  return  to  the  operation.  Before  the  patient 
comes  out  of  the  anesthetic,  the  foot  is  placed  in  plaster- 
of-Paris.  Strips  of  cotton  batting  are  placed  between 
the  toes  to  prevent  their  being  crumpled  up  and  to  keep 
them  flat,  then  batting  is  wrapped  around  the  foot  and 
leg  as  high  as  the  tibial  tubercle.  This  batting  must  be 
thick  enough  to  allow  for  the  swelling  which  will  result 
from  the  manipulation.  Usually  it  should  be  three- 
fourths  of  an  inch  or  more  thick.  As  the  foot  is  to  be 
stood  upon  and  walked  on,  the  bottom  of  the  plaster 
must  be  made  extra  strong.  A  good  way  to  reen  force 
it  is  to  make  a  sole,  by  doubling  back  and  forth  upon 
itself  a  three-inch  plaster  bandage,  making  a  pad  the 
length  of  the  foot,  and  then  binding  it  on  with  another 
plaster  bandage  and  rubbing  it  well  until  thoroughly  set. 
By  making  this  sole  thicker  in  one  part  than  another, 
under  the  inner  side  if  a  valgus  has  been  corrected  or 
under  the  outer  side  if  a  varus  has  been  corrected,  or 
under  the  forefoot  if  the  deformed  condition  was  one  of 
equinus  and  under  the  heel  if  there  was  a  calcaneus,  a 
further  corrective  force  is  obtained.  When  stepped  upon, 
the  thicker  part  of  the  sole  will  push  up  on  the  part  di- 
rectly above  with  more  force  than  will  be  felt  by  the 
other  parts  of  the  foot. 

Over-correction  should  be  the  aim  of  the  operator  and 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  l6l 

the  plaster  bandage  should  be  applied  with  the  foot  in  the 
over-corrected  position.  A  case  of  equino-varus  should 
be  put  up  in  a  position  of  calcaneo-valgus,  or  a  position 
approaching  it  as  nearly  as  possible. 

TENOTOMY 

History. —  The  history  of  subcutaneous  tenotomy 
is  an  interesting  one.  Before  the  day  of  antisepsis,  this 
operation  assumed  an  importance  which  has  been  equaled 
in  few  instances,  I  venture  to  state,  in  the  discovery  of 
any  new  surgical  procedure.  To  Stromeyer  is  due  all 
honor  for  conceiving  it  and  putting  it  into  practice,  and 
to  Little  is  due  all  honor  for  giving  it  a  wide  introduc- 
tion, and  to  Detmould  for  bringing  a  full  knowledge  of 
it  to  this  country. 

Tenotomies,  with  a  more  or  less  open  wound,  had  been 
done  long  before  Stromeyer's  day.  Many  knew  of 
Stromeyer's  work  before  Little  visited  him  as  a  patient 
and  a  student.  Subcutaneous  tenotomies  had  been  done 
in  America  before  Detmould  returned  from  his  studies 
abroad.  The  question  of  priority  is  raised  with  every 
invention  and  discovery,  but  subcutaneous  tenotomy  will 
always  be  associated  with  Stromeyer  and  Little  in  the 
annals  of  surgery;  and  the  profession  in  this  country 
should  remember  the  name  of  Detmould  in  this  con- 
nection. Dr.  Dickson  of  North  Carolina  performed  the 
operation  in  1835  and  Dr.  Smith  of  Baltimore  in  1836, 
while  Detmould  did  not  perform  the  operation  in  New 
York  until  1837;  but  his  is  the  credit  for  advocating  and 


l62  DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

teaching  the  operation  so  that  its  wonderful  possibilities 
became  widely  known  and  countless  thousands  of  cripples 
have  been  greatly  benefited. 

Value. —  In  this  day  of  aseptic  surgery,  some  think 
that  subcutaneous  tenotomy  is  evidence  of  poor  surgical 
skill,  that  an  open  operation  is  better  art.  On  the  con- 
trary, it  requires  greater  skill  cleverly  to  divide  tendons 
subcutaneously  than  through  an  open  wound.  Not  only 
must  the  operator's  knowledge  of  the  anatomy  of  the 
part  be  perfect  but  the  fingers  must  be  very  deft  and 
sensitive.  The  open  method,  in  spite  of  the  advance- 
ment of  aseptic  surgery,  is,  in  many  instances,  disad- 
vantageous to  the  best  results.  Cicatricial  tissue  is  to  be 
avoided  as  much  as  possible  in  the  correction  of  any 
deformity :  not  only  can  it,  of  itself,  cause  a  deformity 
by  its  inevitable  contraction,  but  it  is  a  most  difficult 
tissue  to  stretch.  Subcutaneous  tenotomies  are  much 
quicker  in  the  doing,  there  are  practically  no  wounds  to 
be  dressed  and  there  is  no  interruption  in  the  treatment 
by  apparatus.  Furthermore,  laboratory  experiments 
have  demonstrated  that  new  tendon  is  produced  only  by 
the  tendon  sheath  and  the  peritendoneum,  the  severed 
ends  not  assisting.  If  the  sheath  is  left  intact,  the  width 
of  the  gap  between  the  severed  ends  can  not  be  of  grave 
importance,  providing  the  gap  is  not  so  great  as  to  allow 
of  the  sheath  being  entirely  collapsed  and  drawn  tight 
like  a  whipcord.  So,  even  if  an  open  wound  is  made  to 
reach  the  tendon,  it  is  better  surgery  not  to  open  up  the 
§heath,  if  pimple  tenotomy  is  to  be  performed,  and  thus 


TREATMENT   OF    CONGENITAL    CLUB-FOOT  1 63 

no  gain  is  made  over  the  subcutaneous  method  except  to 
allow  of  seeing  that  none  of  the  neighboring  structures 
is  injured,  an  unnecessary  precaution  for  the  skillful 
surgeon. 

Tendo  Achillis. —  This  was  the  first  tendon  to  be 
divided  by  the  subcutaneous  method.  After  preparation 
of  the  site,  a  narrow-bladed  tenotome  is  inserted  close  to 
the  inner  border  of  the  tendon,  opposite  the  thickest  part 
of  the  internal  malleolus,  where  the  tendon  is  the  nar- 
rowest. The  foot  is  held  in  slight  dorsal  flexion  so  as 
to  bring  the  tendon  into  relief;  and  the  blade,  held  flat 
to  the  tendon,  is  passed  into  the  posterior  part  of  the 
sheath  and  through  to  the  outer  border  of  the  tendon, 
where  it  may  be  felt  by  the  finger.  The  blade  is  now 
turned  with  its  cutting  edge  toward  the  tendon  and  the 
foot  dorsal-flexed  to  its  limit.  If  the  knife  has  been  held 
firmly  this  tightening  of  the  tendon  will  sometimes  be 
sufficient  to  divide  it;  but  if  not,  then  a  few  sawing-like 
movements  will  be  all  that  is  necessary.  A  finger  held 
over  the  tendon  and  pressing  down  upon  it  will  inform 
the  surgeon  of  the  progress  the  blade  is  making.  Some 
surgeons  have  advised  that  the  last  few  fibers  be  torn 
rather  than  cut,  so  as  to  leave  something  of  a  bridge  for 
the  better  growth  of  the  new  tendon;  but  this  (by  our 
fuller  knowledge  of  tendon  regeneration),  is  now  known 
to  be  unnecessary.  The  skin  puncture  can  be  made  with 
a  sharp-pointed  bistoury  if  desired  and  then  the  blunt- 
pointed  one  inserted ;  but  it  is  almost  impossible  to  avoid 
cutting  the  entire  breadth  of  the  posterior  part  of  the 


164  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

sheath  by  such  a  procedure  and  if  the  sharp-pointed  knife 
is  inserted  through  the  skin  on  into  the  sheath  and  then 
withdrawn  and  the  blunt-pointed  one  then  used,  it  is  not 
ahvays  an  easy  matter  to  find  the  opening  in  the  sheath. 
It  is  much  the  better  plan  to  use  the  sharp-pointed 
tenotome  from  start  to  finish.  It  should  not  be  neces- 
sary to  withdraw  the  blade  until  the  operation  is  com- 
pleted. 

The  object  of  subcutaneous  tenotomy  is  lost  if  there 
is  more  than  one  small  puncture  in  the  skin  and  in  the 
tendon-sheath.  The  tenotome  should  have  a  short,  nar- 
row blade  with  a  long  shank.  There  are  many  shapes 
and  sizes  on  the  market,  but  there  is  none  so  good  as  one 
made  by  grinding  down  the  blade  of  an  ordinary  scalpel. 
The  blade  should  be  short  so  that  its  cutting  edge  will 
not  overlap  the  tendon  and  cut  the  sheath.  It  should 
be  narrow  so  that  it  will  not  make  a  long  wound  in 
piercing  the  skin  and  sheath.  It  should  have  a  narrow 
shank  and  a  long  one,  so  that  the  skin  puncture  will  not 
be  needlessly  enlarged  during  the  operation. 

The  wound  is  dressed  with  a  piece  of  sterile  cotton 
dipped  in  a  fifty  per  cent,  solution  of  alcohol.  The  cor- 
rection permitted  by  the  operation  is  immediately 
accomplished  and  if  nothing  more  is  to  be  done,  a  plas- 
ter-of-Paris  dressing  is  applied.  Care  should  be  taken 
that  the  dressing  over  the  gap  in  the  tendon  does  not 
press  into  it  and  thereby  interfere  with  the  generation 
of  the  new  tendon. 

Indications. —  Tenotomy  of  the  tendo  Achillis  is  indi- 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 65 

cated  in  a  marked  equinus  where  the  tautness  of  the 
tendon  on  any  effort  at  dorsal  flexion  proves  it  to  be 
one,  if  not  the  only  one,  of  the  obstructions  to  normal 
movement.  An  open  operation  is  the  method  of  choice 
whenever  the  lengthening  of  the  heel-cord  must  be  two 
inches,  as  the  sheath  will  be  badly  lacerated  if  subjected  to 
greater  extension,  and  also  in  those  cases  where  previous 
operation  has  resulted  in  much  scar  tissue.  Scar  tissue 
will  not  lend  itself  to  extension  but  will  tear  when  much 
force  is  applied;  and  if  the  scar  tissue  includes  the  skin 
a  large  gap  may  result  which  will  have  to  heal  by  granu- 
lating from  the  bottom,  thus  almost  certainly  precluding 
any  resulting  function  on  the  part  of  the  gastrocnemius. 
In  these  cases  and  also  when  an  exact  amount  of  length- 
ening is  desirable,  a  splicing  of  the  tendon  is  the  pro- 
cedure of  choice,  with  a  plastic  operation  for  the  removal 
of  scar  tissue.  The  tendo  Achillis  should  never  be  oper- 
ated upon  until  all  other  deformities  have  been  corrected 
in  so  far  as  is  possible. 

Posterior  Ligament. —  Lying  betw^een  the  tibia  and 
the  astragalus  this  ligament  may  prevent  dorsal  flexion 
after  division  of  the  tendo  Achillis  or  it  may  have  been  the 
only  obstruction  to  correction  of  the  equinus.  Its  division 
is  usually  effected  after  tenotomy  of  the  heel-cord  by 
turning  the  cutting  edge  of  the  tenotome  directly  forward 
toward  the  joint,  when  it  may  be  divided  without  danger 
to  other  structures.  Broca,  however,  preferred  to  ten- 
otomize  the  tendo  Achillis  by  the  open  method,  not  on 
account  of  any  danger  in  that  operation  by  the  sub- 


1 66         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

cutaneous  method,  but  to  be  able  to  cut  this  ligament 
more  easily. 

To  detemiine  what  structure,  whether  muscle,  liga- 
ment, or  bone,  is  preventing  dorsal  flexion,  a  most  care- 
ful analytical  examination  is  necessary.  It  is  a  cruel 
disappointment  to  expect  a  simple  tenotomy  to  cure  an 
equinus  and  to  find  that  the  deformity  persists  after  the 
operation.  That  the  posterior  ligament  is  the  chief  fac- 
tor may  sometimes  be  ascertained  by  noting  that  the 
tension  of  the  tendo  Achillis  is  not  complete  in  forced 
dorsal  flexion,  and  that  bony  obstruction  alone  has  a 
different  "  feel "  as  the  limitation  of  movement  is 
reached.  It  is  well  to  give  a  conservative  prognosis  in 
all  doubtful  cases. 

Tibialis  Posticus. —  Tenotomy  of  this  tendon  was 
first  done  by  Stromeyer  in  1834  and  by  Little  in  1842. 
It  takes  more  skill  than  does  division  of  the  tendo  Achillis 
but,  when  indicated,  no  hesitancy  should  be  felt  by  the 
surgeon  in  undertaking  it.  By  some  surgeons,  notably 
Broadhurst,  it  is  considered  as  demanding  division  in 
nearly  every  case. 

This  operation  can  be  done  in  either  one  of  two  loca- 
tions before  it  reaches  the  end  of  the  tibia  and  while  it 
is  still  in  the  groove  of  that  bone,  or  just  before  its  in- 
sertion into  the  internal  cuneiform.  If  it  is  to  be  divided 
alone,  or  with  the  flexor  longus  digitorum,  the  first  posi- 
tion is  the  one  of  choice.  If  the  tibialis  anticus  and  the 
astragalo-scaphoid  capsule  are  to  be  divided  at  the  same 
operation,  then  the  latter  situation  is  preferable.     In  in- 


TREATMENT   OF    CONGENITAL    CLUB-FOOT  1 67 

f ants  it  is  well  to  follow  Little's  instructions ;  the  teno- 
tome is  entered  one  and  one-half  inches  above  the  tip  of 
the  internal  malleolus,  at  a  point  midway  between  the 
front  and  back  of  the  leg.  It  is  pressed  down  until  the 
posterior  edge  of  the  bone  is  felt.  The  tendon  is  relaxed 
by  exaggerating  the  deformity  and  the  blade  is  slipped 
between  the  tendon  and  the  bone.  Its  cutting  edge  is 
then  turned  toward  the  tendon  and  division  usually  ef- 
fected simply  by  rendering  it  taut.  The  assistant  hold- 
ing the  foot  may  feel  the  snap  more  plainly  than  the 
operator  and  will  notice  the  advancement  toward  cor- 
rection. 

The  greatest  danger  in  performing  this  operation  is 
that  of  wounding  the  posterior  tibial  artery.  Should  this 
happen  it  is  not  necessary  to  cut  down  on  the  artery  and 
tie  it  off;  dressing  with  a  pad  will  stop  the  bleeding. 
The  presence  of  an  abundance  of  bright  red  blood  on 
the  withdrawal  of  the  knife  and  the  sudden  blanching 
of  the  foot,  are  the  indications  of  this  accident.  Should 
this  happen  the  foot  should  be  put  up  in  the  deformed 
position  for  five  days  and  correction  made  after  that 
time. 

The  tibialis  posticus  does  not,  in  equino-varus,  pursue 
its  normal  course.  Its  attachment  to  the  scaphoid  and 
to  the  internal  cuneiform  will  cause  its  direction  to  be 
determined  by  the  altered  position  of  these  bones.  It 
may  take  a  directly  downward  path,  beneath  the  malleo- 
lus ;  or  it  may  go  slightly  forward ;  or,  according  to  one 
writer,  it  may  take  a  course  slightly  backward.     How- 


1 68         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

ever,  it  must,  in  any  case,  cross  the  astragalo-scaphoid 
joint  and  will  therefore  be  divided  at  the  same  operation 
for  the  divisions  of  the  ligaments  of  this  joint. 

Astragalo-Scaphoid  Capsule. —  As  described  by 
Parker,  this  is  "  made  up,  above  and  internally  by  a 
blending  together  of  the  inferior  astragalo-scaphoid  liga- 
ment with  fibers  from  the  anterior  ligament  and  the 
anterior  portion  of  the  deltoid  ligament  of  the  ankle 
joint,  below  the  fibers  from  the  calcaneo-scaphoid  liga- 
ment. To  these  are  united  fibrous  expansions  of  the 
tendons  of  the  anterior  and  posterior  tibial  muscles. 
This  dense  structure  is  fortunately  quite  subcutaneous 
and  so  placed  that  it  can  be  divided  without  risk  to  other 
structures."  Its  division  is  effected  by  inserting  the 
tenotome  close  to  the  anterior  border  of  the  internal 
malleolus,  passing  the  blade  on  the  fiat,  downward,  just 
beneath  the  skin,  for  about  one-half  an  inch  or  until  the 
tip  reaches  the  lowest  plane  of  the  scaphoid,  and  then 
turning  the  edge  inward  and  cutting  directly  into  the 
astragalo-scaphoid  joint. 

Flexor  Longus  Digitorum. —  This  tendon  may  be 
divided  at  the  same  time  as  the  tibialis  posticus  by  push- 
ing the  tenotome  a  little  deeper  and  including  both  ten- 
dons. 

Tibialis  Anticus. —  This  may  be  divided  alone  as  it 
lies  in  front  of  the  ankle  joint.  It  will  be  found  dis- 
placed inward. 

Peroneus  Longus  and  Brevis. —  Both  may  be 
divided  as  they  lie  behind  the  fibula,  about  an  inch  and  a 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  169 

half  above  the  tip  of  the  external  malleolus.  The  teno- 
tome is  passed  on  the  flat  between  the  tendons  and  the 
bone,  and  then  the  edge  turned  outward  and  the  tendons 
divided. 

The  tendons  of  the  extensor  longus  pollicis  and  the 
extensor  longus  digitorum  may  be  divided  anywhere 
between  the  annular  ligament  and  their  points  of  inser- 
tion, due  care  being  taken  not  to  wound  the  anterior 
tibial  artery  which  lies  between  the  tendon  of  the  ex- 
tensor longus  pollicis  and  the  tendon  of  the  extensor 
longus  digitorum.  If  all  the  tendons  of  the  latter  muscle 
are  to  be  divided  it  is  better  to  cut  the  tendon  before  it 
separates  into  its  divisions. 

Plantar  Fascia. —  The  plantar  fascia  and  the  mus- 
cles in  the  sole  of  the  foot  may  be  reached  through  a 
puncture  at  about  the  middle  of  the  length  of  the  internal 
border  or  at  a  point  posterior  to  this;  about  at  the  junc- 
ture of  the  middle  and  the  posterior  thirds.  In  the  latter 
situation  the  scar  tissue  is  less  likely  to  be  troublesome 
and  the  fascia  and  the  muscles  are  in  a  more  compact 
bundle  and  therefore  more  capable  of  thorough  division. 
After  the  skin  puncture  is  made  the  tenotome  may  be 
passed  between  the  skin  and  the  fascia  and  the  incision 
made  toward  the  bone ;  or  it  may  be  passed  deeply,  under 
the  constricting  bands,  and  the  cutting  done  toward  the 
skin.  Whichever  procedure  is  followed,  the  operation 
must  be  thorough,  no  band  of  fascia  or  contracted  muscle 
must  be  left.  After  the  most  prominent  ones  have  been 
divided,  abduction  and  dorsal  flexion  of  the  forefoot  by 


170         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

the  assistant  will   usually   bring  the   deeper   ones   into 
relief. 

Danger  of  Aneurism. — In  performing  the  operation 
of  tenotomy,  some  surgeons  advise  the  use  of  a  blunt- 
pointed  bistoury  after  the  skin  puncture  is  made,  so  as  to 
avoid  the  pricking  of  an  artery;  as  a  slight  prick  may 
result  in  the  formation  of  an  aneurism  while  a  free  di- 
vision of  an  artery  will  cause  little  or  no  trouble. 

Indications  for  Tenotomy. —  In  determining 
whether  or  not  tenotomies  are  indicated  in  any  case  of 
deformities  of  the  foot,  the  following  points  may  prove 
useful : 

In  infants  all  the  tissues  will  yield  to  manipulation. 
Through  faulty  manipulation,  from  whatever  cause,  one 
or  more  tendons  may  subsequently  need  to  be  divided. 

Improvement  in  congenital  cases  should  be  steadily 
progressive.  When  improvement  is  arrested,  there 
should  be  no  hesitancy  in  operating  upon  the  offending 
structures. 

When  the  child  begins  to  stand,  the  foot  must  be  in 
a  normal,  or  better,  in  an  over-corrected  position. 

Tenotomy  of  the  tendo  Achillis  should  not  be  per- 
formed until  all  deformities  except  the  equinus  are 
corrected. 

In  congenital  cases  of  club-foot  the  tendons  are  the 
chief  cause  of  the  deformities  at  birth;  the  ligaments 
become  factors  after  a  few  months,  the  bones  assuming 
a  constantly  increasing  importance  after  the  first  year. 
Little  advised  tenotomies  at  about  the  eighth  or  ninth 


TREATMENT   OF    CONGENITAL    CLUB-FOOT  I7I 

month,  Adams  at  about  the  second  month,  and  Broad- 
hurst  at  an  early  period  even  in  cases  of  slight  degree. 

In  infants  the  plantar  fascia  is  seldom  a  serious  obstacle 
to  correction. 

The  tendon  of  the  tibialis  posticus  is  of  more  impor- 
tance in  preventing  correction  of  the  varus  than  any- 
other  one  tendon,  the  tibialis  anticus  being  the  next  in 
importance. 

The  astragalo-scaphoid  ligament  or  rather  the  capsule 
which  includes  this  ligament  and  part  of  the  deltoid  as 
well,  needs  division  much  more  frequently  than  does  any 
other  ligament. 

In  adults  there  are  certain  cases  which  yield  to  tenot- 
omy alone.  Broadhurst  relates  a  case,  fifty-two  years 
old,  "  having  one  of  the  most  severe  forms  of  congenital 
equino-varus  that  I  ever  saw,"  so  far  relieved  by  tenoto- 
mies that  he  could  walk  with  the  sole  flat  on  the  ground 
and  free  ankle  movement.  Also  a  case  seventy-three 
years  old,  cured  by  tenotomies  only,  so  that  "  no  vestige 
of  deformity  remained."  However,  the  more  a  deform- 
ity is  used  the  greater  will  be  the  changes  which  confirm 
it  and  we  should  therefore  always  expect  to  find  more 
or  less  marked  changes  in  the  bones  in  these  old  cases. 

In  adults,  the  mere  presence  of  deformity  in  the  foot 
is  not  always  sufficient  reason  for  attempting  to  correct 
it.  E.  Duval  relates  a  case,  quoting  Malgaigne,  of  an 
adult  with  congenital  club-foot  who  could  walk,  run,  and 
ride.  He  was  operated  upon  and  afterward  it  took  him 
six  hours  to  walk  a  distance  which  he  could  have  covered 


.172  DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

in  one  hour  before  the  operation.  A  Dr.  Mazet  himself 
suffered  from  congenital  club-foot,  but  attended  to  a 
large  practice.  He  was  operated  upon  and  found  him- 
self worse  off  than  before.  After  a  second  operation 
he  was  forced  to  give  up  walking  altogether  and  to  de- 
pend entirely  on  his  carriage.  These  unfortunate  results 
are  instructive  as  a  warning  to  be  chary  of  a  too  opti- 
mistic prognosis  in  confirmed  cases  of  long  standing. 
However,  tenotomies  are  seldom  followed  by  a  worse 
condition  than  that  for  which  they  were  done,  and  usually 
some  improvement,  if  not  a  perfect  cure,  results. 

Phelps'  Operation. —  This  is  essentially  a  division 
by  open  operation  of  all  the  resistant  tissues  on  the  inner 
side  of  the  foot.  At  first  it  was  limited  to  the  soft  parts, 
but  later,  osteotomy  was  done  if  necessary.  For  some 
years  the  operation  was  performed  quite  generally,  here 
and  abroad,  but  it  has  now  fallen  into  disuse  except  in 
some  specially  indicated  and  unusual  cases.  The  soft 
parts  can  usually  be  divided  quite  as  well  by  the  sub- 
cutaneous method  and  if  bone  operation  is  necessary,  it 
had  better  be  done  through  a  flap  incision. 

BONE   OPERATIONS. 

Indications. —  While  the  bones  of  the  foot  are  plas- 
tic they  readily  yield  to  any  force.  This  plasticity  lessens 
with  age,  until  about  the  eighth  year,  when  their  ossifica- 
tion is  completed.  Pressure  and  movements,  before  this 
time  is  reached,  determine  their  conformation  and  the 
extent  of  their  articular  surfaces;  while  afterwards  these 


TREATMENT   OF    CONGENITAL    CLUB-FOOT  1 73 

forces  act  very  slowly  indeed  in  their  influence  on  bone- 
formation.  This  statement  appHes  with  equal  force  to 
the  formation  of  deformities  as  well  as  to  their  correc- 
tion. 

Until  the  age  of  weight-bearing  arrives,  pressure  and 
movements  are  determined  solely  by  the  muscles  and 
ligaments.  After  weight-bearing  begins,  the  influence 
of  the  muscles  and  ligaments  in  directing  pressure  and 
limiting  movements  continues,  unless  they  are  put  at  rest 
by  an  immobilizing  splint  such  as  a  plaster-of-Paris 
dressing. 

If  operation  on  the  soft  parts  permits  of  correction  of 
deformity,  the  placing  of  the  bones  in  their  normal  rela- 
tion to  each  other,  whether  or  not  inter-articular  cartilage 
perfectly  intervenes;  and  if  functionating  takes  place, 
then  a  cure  may  be  expected.  On  the  other  hand,  if 
correction  of  deformity  follows  operation  on  the  soft 
parts  but  with  much  separation  of  bony  surfaces,  a  cure 
is  not  likely  to  result.  New  articular  surfaces  will  not 
form  if  the  surfaces  are  not  in  contact  and  moving  upon 
each  other ;  nor  will  bony  growth  take  place  if  the  stimu- 
lation of  weight-bearing,  or  some  force  transmission,  is 
not  present ;  nor  will  exuberant  bone  be  absorbed  by  fric- 
tion and  pressure  if  friction  and  pressure  do  not  exist. 
If  the  separation  of  bony  surfaces  after  operation  and 
correction  of  deformity  is  slight,  then  absorption  of  the 
fulcrum  which  is  holding  the  surfaces  apart  may  result 
in  the  closing  of  the  gap  and  the  establishment  of  a 
permanent  cure. 


174         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

Bones  to  be  Attacked. —  The  bony  obstructions  to 
the  correction  of  congenital  equino-varus,  the  most  com- 
mon of  the  congenital  varieties  requiring  operative  inter- 
ference, are  confined  practically  to  the  astragalus  and  the 
OS  calcis.  The  astragalus  presents  a  deformed  head  and 
an  exuberance  of  bony  growth  in  front  of  the  articular 
facet  for  the  fibula.  There  may  also  be  a  ridge  of  bone 
across  the  trochlear  surface  effectually  preventing  dorsal 
flexion.  The  os  calcis  presents  on  the  external  part  of 
its  anterior  surface,  which  is  normally  occupied  by  part 
of  the  articular  surface  for  the  cuboid,  an  exostosis  which 
mechanically  interferes  with  the  reposition  of  the  cuboid 
to  its  normal  location. 

Astragalectomy. —  By  total  removal  of  the  astrag- 
alus, all  bony  obstruction  to  correcting  inversion  and 
equinus  are  abolished,  but  the  anterior  part  of  the  os 
calcis  may  still  prevent  abduction.  If  the  equinus  is  the 
chief  deformity,  the  partial  removal  of  the  astragalus 
may  be  performed,  as  recommended  by  Tubby :  "  If  the 
foot  itself  is  entirely  straight  with  the  leg,  and  the  de- 
formity is  only  at  the  ankle  joint,  partial  removal  suffices. 
But  if  inversion  is  combined  with  absence  of  dorsal 
flexion,  the  whole  bone  must  be  removed."  In  partial 
removal  he  takes  away  only  the  upper  half  of  the  bone. 

Astragalectomy  was  first  performed  by  Lund  in  1872. 
The  incision  is  made  on  the  outer  side  of  the  foot,  ex- 
tending from  behind  the  external  malleolus,  about  an 
inch  above  its  tip,  downward,  and  forward  to  the  fifth 
metatarsal.     After  elevation  of  the  soft  parts,  the  exact 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 75 

positions  of  the  tibio-tarsal  and  of  the  astragalo-scaphoid 
joints  are  determined  and  the  astraglo-scaphoid  ligament 
is  divided.  The  detachment  of  the  external  lateral  liga- 
ments will  permit  sufficient  loosening  of  the  bone  to  allow 
of  its  being  seized  with  bone-forceps  and  so  twisted 
that  the  internal  lateral  ligament  may  be  reached  with 
knife  or  scissors.  After  that  the  interosseous  ligament 
is  divided  and  the  bone  removed.  Sometimes  it  may  be 
easier  to  remove  the  bone  in  two  sections,  the  head  and 
neck  being  chiseled  off  before  the  body  is  attacked.  If 
after  excision  of  the  astragalus,  it  is  found  that  abduc- 
tion is  impossible,  the  exuberant  bone  on  the  os  calcis 
which  is  blocking  reposition  of  the  cuboid,  must  be 
chiseled  away.  This  can  be  done  through  the  incision 
already  made.  It  is  seldom  necessary  to  disturb  the 
integrity  of  the  cuboid,  and  if  this  is  not  done,  a  service- 
able joint  will  result. 

Partial  Excision. —  It  would  seem  that  instead  of 
removing  the  entire  bone,  it  should  be  possible  to  clear 
away  the  obstructions  to  reposition  and  leave  the  body 
of  the  astragalus  undisturbed.  If  one  can  satisfy  him- 
self, by  his  examinations  and  radiographs,  that  the  ob- 
stacle to  correction  is  confined  to  the  head  and  neck,  the 
excision  of  this  part  may  be  sufficient  or  this  operation 
combined  with  resection  of  the  head  of  the  os  calcis. 
This  was  the  procedure  advised  by  Broca  in  both  the 
child  and  the  adolescent.  After  ten  years  of  such  prac- 
tice, he  said  that  the  facts  disprove  the  theory  of  its 
interference  with  osteogenesis. 


176  DISEASES    AND   DEFORMITIES    OF    THE   FOOT 

Ogston's  Operation. —  This  operation  is  devised 
for  the  correction  of  congenital  deformities  of  the  foot. 
It  consists  of  the  removal  of  the  ossified  center  or  kernel 
of  the  deformed  bone  and  the  consequent  reduction  of 
the  bone  to  an  entirely  cartilaginous  state  permitting  of 
immediate  re-shaping  of  its  external  configuration. 
Ligaments,  muscles,  and  joints  are  left  undisturbed.  It 
is  applicable  until  after  the  sixth  year,  or  until  the  ossifi- 
cation has  not  advanced  too  far  when,  of  course,  the 
operation  would  be  tantamount  to  excision. 

For  congenital  equino-varus  the  incision  is  curved 
from  just  in  front  of  the  external  malleolus,  forward  to 
the  dorsal  aspect  of  the  calcaneo-cuboid  joint,  with  the 
convexity  toward  the  sole.  An  incision  is  made  into 
the  head  of  the  astragalus,  and  with  a  Volkmann  spoon 
the  ossified  center  is  scooped  out.  The  body  of  the 
astragalus  is  treated  in  the  same  way,  and  if  necessary,  the 
same  treatment  is  given  to  the  os  calcis  and  to  the  cuboid. 
A  radiograph  will  aid  in  determining  whether  the  growth 
of  the  bones  has  passed  beyond  the  stage  when  this 
operation  is  feasible. 

Cuneiform  Tarsectomy. — This  is  the  removal  of  a 
wedge-shaped  piece  from  the  tarsus,  irrespective  of  the 
exact  bones  operated  upon.  The  foot  being  considered 
as  a  solid  mass,  the  wedge  is  removed  to  permit  the 
restoration  of  the  contour  regardless  of  the  exact  bones 
and  joints  involved  in  the  operation. 

Multiple  Cuneiform  Osteotomies. —  Hoke  has  very 
successfully  treated  a  number  of  relapsed  and  untreated 


TREATMENT    OF    CONGENITAL    CLUB-FOOT  1 77 

cases  of  congenital  equino-varus  by  carefully  planned 
cuneiform  osteotomies  of  several  of  the  tarsal  bones, 
including  the  internal  cuneiform,  cuboid,  os  calcis,  and 
the  astragalus.  He  also  shifted  the  external  malleolus 
forward  by  fracturing  the  fibula  one  and  one-half  inches 
above  the  tip  of  the  malleolus. 


CHAPTER  VII 

POTT'S  PARAPLEGIA.  CEREBRAL 
PARALYSIS 

PARALYSIS    COMPLICATING    POTt's   DISEASE 

As  the  majority  of  these  cases  recover  and  as  during 
its  presence  no  one  would  think  of  allowing  any  attempt 
at  using  the  feet,  it  is  necessary  only  to  prevent  passive 
stretching  of  the  muscles  and  ligaments  of  the  foot  un- 
til their  normal  strength  has  returned.  The  foot  should 
be  held  by  some  simple  retentive  apparatus  at  a  right 
angle  to  the  leg.  A  padded  tin,  gutter  splint  is  easy 
to  construct  and  meets  all  the  indications.  No  passive 
exercises  or  massage  should  be  prescribed  during  the 
period  in  which  the  reflexes  are  markedly  active. 

SPASTIC    PARALYSIS 

As  this  condition  is  usually  such  as  to  demand  as  much 
or  more  attention  to  other  parts  of  the  body  than  to  the 
feet,  a  general  discussion  will  not  be  attempted,  the 
reader  being  referred  to  works  on  general  orthopedic 
surgery.  Sometimes,  however,  the  foot  in  hemiplegia, 
or  both  feet  in  diplegia,  will  present  the  most  noticeable 
abnormality  and  therefore,  treatment  as  directed  toward 
the  feet  will  be  outlined. 

178 


pott's  paraplegia,     cerebral  paralysis       179 

Diagnosis. —  The  most  marked  spasm  is  usually  in 
the  gastrocnemius  and  the  soleus,  producing  equinus,  but 
the  inverters  of  the  sole  and  the  adductors  of  the  forefoot 
are  also  involved  and  a  talipes  equino-varus  may  exist, 
with  the  patient,  if  able  to  walk  at  all,  walking  on  the 
outer  border  of  the  forefoot  or  even  on  the  dorsum. 
Although  the  non-spastic  muscles  are  more  or  less  para- 
lyzed from  the  constant  stretching  to  which  they  are 
subjected,  atrophy  of  the  leg  is  not  very  noticeable; 
doubtless  hypertrophy  of  the  over-acting  muscles  hides 
much  of  the  atrophy. 

Examination. —  If  one  grasps  the  foot  jfirmly  and 
attempts  to  restore  it  to  its  normal  position,  resistance 
will  be  met,  which  will  yield,  much  as  would  a  stout  rub- 
ber band,  to  a  steady  pressure.  This  is  called  "  lead 
pipe  contracture "  by  Weir  Mitchell.  The  deformity 
is  at  once  resumed  upon  removal  of  the  pressure. 

Treatment. —  In  an  untreated  case  it  is  impossible 
to  determine  in  advance  how  much  may  be  expected  from 
such  measures  as  look  to  the  relief  of  the  stretching  of 
the  non-spastic  muscles  and  the  restoration  of  their  power. 
A  brace  should  be  designed  to  hold  the  foot  in  the  best 
possible  position  without  pain.  Such  a  brace  will  have 
to  be  worn  inside  the  shoe  —  as  the  strength  of  the  spastic 
muscles  would  distort  the  shoe  in  an  outside  ankle  brace. 
Massage  and  unassisted  active  movements  of  the  muscles 
which  have  been  the  subject  of  the  stretching,  may  be 
practiced  three  times  a  day,  but  such  treatment  must 
absolutely  be  limited  to  these  muscles. 


l8o         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

Sometimes  the  spasms  are  lessened  by  putting  the 
muscles  at  complete  rest,  with  the  foot  in  an  improved 
position,  in  a  plaster-of-Paris  dressing  for  several  weeks. 
This  measure  is  recommended  at  the  beginning  of  treat- 
ment in  all  cases  of  pronounced  severity. 

Tenotomies. —  These  will,  of  course,  remove  imme- 
diately all  influence  on  the  joints  of  the  spasmodic  mus- 
cles; but  after  the  tendons  have  united  their  influence 
will  again  be  exerted.  Before  this  union  takes  place, 
much  may,  however,  be  gained  by  massage  and  exercise 
of  the  other  muscles.  Furthermore,  the  rest  obtained 
by  the  nervous  system  after  tenotomy  is  beneficial  to 
the  general  condition.  As  a  rule  operation  is  not  ad- 
visable immediately  after  a  case  comes  under  treatment. 
If  braces  can  be  made  to  overcome  the  spasmodic  muscles, 
tenotomies  can  be  advantageously  postponed  for  some 
months  or  even  years;  especially  as,  in  many  of  these 
cases,  there  comes  a  time  when  the  spasms  diminish  in 
intensity,  contractures  form,  and  the  result  of  a  tenotomy 
will  then  be  more  enduring.  After  tenotomy  of  these 
muscles,  if  the  spasm  is  very  pronounced,  the  proximal 
end  is  drawn  some  distance  from  the  distal  end  and 
therefore  it  is  well  to  put  the  foot  up  at  a  greater  angle 
than  90  degrees,  so  as  to  assure  a  firm  union. 

Neurotomy. —  The  reports  of  many  observers  that 
after  simple  tenotomy  of  the  tendo  Achillis  in  these 
cases,  the  spasms  in  all  the  muscles  of  the  extremiity 
frequently  lessened,  and  even  the  mental  condition  im- 
proved,  led  me  to  perform  intraperineural  neurotomy 


pott's  paraplegia,     cerebral  paralysis       i8i 

so  as  to  give  a  more  widely  distributed  and  a  more  pro- 
longed rest  to  the  muscles.  The  results  in  two  cases 
operated  were  very  encouraging  and  were  reported  in 
the  American  Orthopedic  Journal  of  November,  1909. 
In  both  of  these  the  sciatic  was  temporarily  paralyzed. 
More  recently  I  divided  and  sutured  the  posterior  tibial 
nerve  and  the  branch  from  the  internal  popliteal  to  the 
soleus.  This  left  the  nerve  supply  to  the  skin  unim- 
paired and  did  not  affect  the  muscles  supplied  by  the 
external  popliteal.  Thus  the  stretched  and  weakened 
dorsal-flexors  and  abductors  could  be  strengthened  and 
shortened  by  exercise  and  massage.  As  the  supply  to  the 
gastrocnemius  was  uninterrupted,  the  tendo  Achillis  was 
divided.  The  result  in  this  case  was  excellent.  After 
the  tendo  Achillis  had  united,  the  patient  could  walk 
with  the  foot  in  the  normal  position. 

Injections  of  Alcohol. —  These  have  been  made  into 
the  nerve  by  Schwab  and  Allison.  However,  an  opera- 
tion is  necessary  to  expose  the  nerve  to  be  injected  and 
the  paralysis  from  nerve-block  is  not,  in  my  opinion,  of 
sufficiently  long  duration  to  warrant  the  procedure. 
They  have  given  many  reports  of  their  cases  and  they 
themselves  are  greatly  encouraged  by  their  results. 

Stoeffel's  Technique. —  Stoeffel  *  lessens  the  aggre- 
gate energy  of  a  spastic  muscle  by  reducing  the  number 
of  its  active  parts.  This  he  does  by  severing  and  re- 
secting the  motor  nerve  funiculi  of  these  parts.     His 

*  "The  Treatment  of  Spastic  Contractures,"  Adolf  Stoeffel,  Mann- 
heim.   The  American  Journal  of  Orthopedic  Surgery.    May,  1913. 


1 82  DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

object  is  to  reduce  the  energy  of  the  spastic  muscle, 
leaving  only  power  enough  for  it  to  perform  its  work 
as  it  would  under  normal  conditions.  In  a  severe  case 
of  spastic  pes  equinus  he  resects  two-thirds  of  the  nerve 
branches  to  the  gastrocnemius  and  half  of  the  supply 
to  the  soleus.  In  slight  cases,  one-third  of  the  nerve 
branches  to  the  gostrocnemius  and  half  the  supply  to 
the  soleus.  In  both  cases  he  destroys  the  nerves  to  the 
digital  flexors.  In  abqut  one  hundred  of  these  nerve 
operations  in  various  conditions  and  localities,  he  has 
never  experienced  a  lesion  of  the  nerve  tract  that  was  not 
intended.  It  will  be  at  once  apprehended  that  a  remark- 
able knowledge  of  anatomy,  experience  in  dissecting  and 
skill  in  operating  are  demanded.  Stoeffel  himself  warns 
against  this  operation  being  undertaken  unless  the  sur- 
geon has  fitted  himself  for  this  work. 


CHAPTER  VIII 

INFANTILE  PARALYSIS 

Residual  Paralysis. —  The  residual  paralysis  after 
an  attack  of  anterior  poliomyelitis,  more  often  affects 
the  muscles  controlling  the  foot  than  any  other  group, 
and  of  this  group  the  tibialis  anticus  is  the  one  most 
frequently  left  in  a  paralyzed  condition.  Not  only  is 
it  uncertain  as  to  the  exact  limit  of  time  after  an  attack 
of  this  disease,  when  improvement  may  be  expected 
from  resuscitation  of  the  cells  in  the  anterior  cornua, 
probably  six  months  and  perhaps  longer;  but  paralysis 
may  remain,  after  the  nerve  cells  have  entirely  recovered, 
from  stretching,  atrophy,  and  degeneration  of  the  mus- 
cles. Therefore  it  is  essential  that  before  any  operation 
is  undertaken  the  existing  cause  of  the  paralysis  be  un- 
questionably ascertained.  Theoretically  electricity  of- 
fers a  means  of  determining  whether  the  nerve-cell  or 
the  muscular  structure  is  at  fault  and  it  is  certainly  of 
great  value  in  the  hands  of  an  expert.  To  the  ordinary 
surgeon,  however,  especially  when  the  patient  is  a  child, 
the  technique  is  too  difficult  of  application  to  be  en- 
tirely satisfactory.  The  best  way  to  satisfy  oneself  that 
the  paralysis  is  permanent  is  to  treat  the  doubtful  muscles 
for  a  prolonged  period  as  though  a  return  of  power  was 

183 


1 84 


DISEASES    AND    DEFORMITIES    OF    THE    FOOT 


expected.  Even  when  contractures  have  not  formed, 
gravity,  or  use  in  a  deformed  position,  may  stretch  and 
prevent  the  return  of  power  to   muscles  histologically 


Fig.  6i.  Dangle-Foot 
From  photograph  of  child  with  complete  paralysis  of  the  lower 
extremities.  The  child  is  seated  on  the  end  of  a  table  with  the  feet 
dangling.  Gravity  has  placed  the  feet  in  the  position  of  equinus 
and  slight  inversion ;  the  position  directed  by  the  shape  of  the 
articulations,  uninfluenced  by  muscles. 

intact  and  sound.  For  instance,  an  equinus  position  re- 
tained at  a  flail  ankle  on  account  of  gravity,  may  be  suffix 
cient  to  continue  a  paralysis  of  the  dorsal  flexors  after 
their  cornual  cells  have  quite  recovered. 


Plate  III. — Flail-Ankle  Sltpported  by  Silk  Ligaments 


All  the  muscles  passing  over  the  ankle  were  paralyzed.  The 
foot  presented  a  cavus  deformity  due  to  contractures  of  the 
plantar  tissues.  Silk  ligaments  were  inserted  and  the  photo- 
graph shows  how  well  they  supported  the  foot  ten  months  after 
the  operation.    Patient  is  seated  on  a  table,  the  foot  hanging  free. 


INFANTILE    PARALYSIS  1 85 

Diagnosis. —  By  placing  a  finger  on  a  tendon,  a  con- 
traction may  be  felt  which  is  too  weak  to  be  demon- 
strated by  any  visual  movement.  Even  the  slightest 
voluntary  contraction  o£  a  muscle  is  proof  that  its  nervous 
mechanism  is  intact,  at  least  in  part,  and  therefore  the 
prognosis  for  that  muscle  is  good.  The  degeneration 
of  muscle  fibers  may  be  extensive,  yet  diligent  attention 
to  the  details  of  treatment,  over  a  prolonged  period,  will 
often  be  rewarded.  Muscles  have  regained  their  func- 
tions after  years  of  disuse. 

These  remarks  are  especially  of  weight  when  the  ques- 
tion of  an  operation  arises  which  would  not  be  necessary 
should  one  or  more  of  the  inactive  muscles  prove  to 
be  sound.  As  to  arthrodesis,  it  should  not  be  performed 
in  any  case  on  the  child  with  growing  bones.  The  inter- 
ference with  the  length  of  the  leg  will  not  be  so  great 
after  arthrodesis  of  the  ankle  as  after  that  operation  on 
the  knee  joint,  but  postponement  of  this  operation  on 
the  child  is,  as  a  rule,  to  be  made. 

Paralysis  of  the  foot  from  infantile  paralysis  will  be 
taken  up  under  three  divisions;  recent  cases,  untreated 
cases  of  long  standing,  and  cases  of  undoubted  permanent 
paralysis. 

RECENT    CASES 

We  shall  not  concern  ourselves  with  the  general  treat- 
ment but  confine  ourselves  to  the  foot.  The  primary 
object  is  to  preserve  the  health  fulness  of  all  the  struc- 
tures :  bones,  ligaments,  and  muscles.     While  strain  and 


1 86         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

stretching  are  prevented,  normal  function  should  be  ex- 
ercised in  so  far  as  possible.  Whatever  will  assist  in 
obtaining  these  ends  must  be  accepted  as  valuable. 

Apparatus. —  Of  whatever  material  it  is  made,  the 
object  of  an  apparatus  is  to  prevent  the  strain  of  the 
muscles  and  ligaments  from  the  action  of  the  sound 
muscles,  from  gravity,  and  from  weight-bearing  in  a 
faulty  position  and  simultaneously  permit  as  much  func- 
tionating as  possible. 

Active  Movements. —  When  all  the  muscles  are  not 
paralyzed,  those  which  have  escaped  must  be  exercised 
or  suffer  atrophy.  Exercise  is  given  by  removing  the 
apparatus  and  by  having  the  sound  muscles  voluntarily 
contracted  against  the  resistance  of  the  nurse's  hand. 
For  instance,  if  the  calf  muscles  are  paralyzed,  the  patient 
is  told  to  draw  the  foot  up,  in  dorsal  flexion,  while  the 
hand  of  the  nurse  resists  the  movement  sufficiently  to 
increase  the  work  done  and  at  the  same  time  prevents 
hyperflexion.  Thus  the  anterior  muscles  are  exercised 
while  over-stretching  of  the  calf  muscles  and  of  the 
posterior  ligament  of  the  ankle-joint  is  prevented. 

Voluntary  contraction  of  a  muscle  is  far  superior  to 
massage  or  to  contraction  from  an  external  stimulant, 
such  as  electricity.  Therefore  attempts  should  be  made 
to  contract  the  paralyzed  muscles  voluntarily.  In  the 
above  exercises  for  the  preservation  of  the  anterior 
muscles,  in  order  to  keep  diligently  attempting  to  contract 
the  calf  muscles,  the  child  should  be  told  to  try  to  extend 
the  foot  when  the  nurse  brings  the  foot  into  extension. 


INFANTILE    PARALYSIS  1 87 

If  the  movements  are  done  rhythmically  it  is  much  better 
than  spasmodically;  and  if  but  one  foot  is  paralyzed, 
the  other  should  voluntarily  be  put  through  the  same 
movements  synchronously  with  the  one  being  exercised. 
It  will  be  found  to  be  of  assistance  if  the  commands  are 
given  in  a  sing-song  fashion,  as:  "up!"  "down!" 
"up!"  "down!" 

What  may  be  accomplished  by  these  exercises  when 
they  are  done  conscientiously,  three  times  a  day,  for  weeks 
and  perhaps  months,  seems  little  short  of  miraculous. 
The  patience,  time,  and  trouble  are  amply  rewarded  if 
voluntary  power  does  return ;  for  no  transplanted  muscle 
can  equal  the  restored  normal  muscle. 

Massage. —  This  is  especially  indicated  for  the 
paralyzed  muscles.  It  is  of  undoubted  value  in  preserv- 
ing the  muscle  tissue.  Degeneration  and  atrophy  are 
at  least  delayed.  Not  only  are  the  muscles  benefited 
but  also  the  skin,  blood  vessels,  ligaments,  and  even  the 
bones.  The  therapeutic  value  of  massage  is  principally 
from  the  increased  flow  of  blood  and  lymph  which  it 
causes;  the  carrying  away  of  effete  material,  and  the 
supplying  of  material  necessary  to  the  maintenance  of 
health.  The  stimulation  of  nerves  not  paralyzed,  the 
sensory  nerves  and  the  nerves  to  other  structures  than 
the  paralyzed  muscles,  is  probably  of  value  also.  There- 
fore massage  should  be  deep  and  with  long,  gentle  strokes, 
so  as  to  empty  the  deeper  vessels ;  and  not  a  simple  rub- 
bing of  the  skin.  It  is  very  important,  however,  that  it 
be  borne  constantly  in  mind  that  paralyzed  muscles  are 


l88         DISEASES    AND    DEFORMITIES    OF   THE    FOOT 

weak,  they  can  not  stand  rough  handling,  and  massage 
such  as  kneading  may  do  more  harm  than  good. 

Electricity. —  This  is  of  value  as  a  stimulant  to 
contraction  of  muscle  fiber.  If  the  stimulation  is  carried 
to  the  muscle  fibers  through  a  nerve,  it  may  help  to  pre- 
serve the  health  of  the  nerve  as  well,  but  on  this  point 
I  know  of  no  physiological  data  from  the  laboratory. 
As  has  already  been  stated,  voluntary  contraction  is  the 
best  preservation  of  the  health  of  a  muscle,  but  where  this 
is  impossible,  on  account  of  the  paralysis,  the  muscle 
fiber  contraction  from  an  external  stimulus  is  the  next 
best  measure.  Usually  the  galvanic  current  will  be 
necessary;  but  as  soon  as  the  nervous  mechanism  begins 
to  be  reestablished,  the  faradic  current  may  be  used. 
Two  or  three  contractions  are  all  that  should  be  made 
at  any  one  seance.  More  will  exhaust  the  fibers  and 
hasten  atrophy.  Electricity  is  probably  of  no  value  ex- 
cept where  it  causes  contraction  of  muscle  fiber. 

Heat. —  The  temperature  of  the  paralyzed  parts  is 
lowered,  not  only  as  a  result  of  the  paralysis  of 
the  nerves  supplying  the  vessel-walls  and  the  conse- 
quently sluggish  blood  stream;  but  as  a  result  of  the  in- 
activity of  the  various  structures,  which  slows  the  blood 
and  thereby  allows  greater  dissipation  of  heat  before 
it  is  renewed.  It  is  of  the  greatest  importance  that  the 
normal  temperature  be  maintained  as  nearly  as  possible. 
This  may  be  accomplished  to  a  great  extent  by  pre- 
venting conduction  through  unconfined  air.  Extra  cloth- 
ing, as  two  pairs  of  stockings,  should  be  worn.     What- 


INFANTILE    PARALYSIS  1 89 

ever  means  are  taken,  the  surgeon  should  satisfy 
himself  that  the  object  is  being  attained  and  should 
bandage  the  foot  and  leg  in  cotton-wool  should  it  be- 
come necessary.  External  heat  may  be  applied  with 
benefit  just  before  each  seance  of  exercises,  massage, 
and  electricity,  such  as  the  heat  from  an  open  fire  or 
the  application  of  warm  clothes;  but  the  extra  clothing 
should  be  sufficient  for  the  rest  of  the  time. 

Functional  Use. —  This  is  the  best  therapeutic 
measure  for  obtaining  normal  growth.  It  must  be  lim- 
ited, as  any  apparatus  efficient  in  protecting  the  para- 
lyzed muscles  and  the  weakened  ligaments  from  strain, 
must  limit  exceedingly,  if  it  does  not  entirely  prevent, 
the  use  of  the  unaffected  muscles.  The  function  of 
weight-bearing  is  of  inestimable  value  in  stimulating  the 
growth  of  the  bones  and  indirectly  in  increasing  the 
temperature  of  the  foot.  It  should  therefore,  be  pro- 
vided for  and  encouraged  in  every  instance. 

UNTREATED    CASES    OF    LONG   STANDING 

The  fact  that  this  class  has  had  no  treatment,  or  only 
treatment  of  a  negligible  quality  or  quantity,  or  both, 
raises  a  question  which  is  all  important  in  our  prog- 
nosis :  Are  the  apparently  paralyzed  muscles  beyond  the 
possibility  of  repair?  The  electrical  reaction  will  tell 
much,  but  personally  I  prefer,  whenever  possible,  to  be- 
gin treatment  with  the  aim  of  giving  each  muscle 
an  opportunity  to  reassert  itself.  Therefore  operation 
should,  I  feel,  be  limited  to  the  replacing  of  the  struc- 


190 


DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


tures  of  the  foot  in  their  normal  relations  and  this  should 
be  followed  by  the  treatment  laid  down  for  riecent  cases. 
In  these  cases  we  have  either  the  flail  joint  of  the 
ankle  with  more  or  less  deformity  of  the  foot  resulting 
from  paralysis  of  all  the  muscles,  and  from  the  foot's 


Fig.  62.    Paralytic  Talipes  Valgus 
The  only  muscular  power  was  expressed  by  a  slight  ability  to  flex 
the   smaller  toes.    Astragalectomies   were  performed  with  marked 
improvement. 

being  used  while  in  this  condition;  or  we  have  deformi- 
ties resulting  from  shortening  of  healthy  structures, 
muscles  and  ligaments,  from  stretching  of  unused  muscles 
and  of  unprotected  ligaments,  and  from  changes  in  some 
of  the  bones,  resulting  from  their  being  used  to  bear 
weight  and  aid  in  progression  while  retained  in  one  po- 


INFANTILE    PARALYSIS 


191 


sition  or  at  least  while  not  enjoying  their  normal  range 
of  motion. 

Some  of  the  acquired  deformities  following  paralysis 
are: 

Valgus. —  This  is  the  most  common  and  accom- 
panies paralysis  of  the  tibialis  anticus  or  of  both  the  an- 
ticus  and  posticus.     Sometimes  it  is  associated  with  a  re- 


Fig.  63  Fig.  64  Fig.  6s 

Examples    of   Equinus    Deformity 

If  Fig.  6s  is  used  in  standing  and  walking,  it  may  progress  to  the 

deformity  seen  in  Fig.  64.     Fig.  65  becomes  more  confirmed  in  the 

deformed  position  without  the  contour  of  the  foot  becoming  much 

altered. 

sidual  weakness  of  the  other  anterior  tibial  muscles,  in 
which  case  there  is  usually  a  shortening  of  the  tendo 
Achillis  and  an  equino-valgus  rather  than  a  pure  valgus. 
Varus. —  This  is  rather  uncommon.  It  results 
from  paralysis  of  the  peroneals.  The  deformity  does 
not  become  extreme  and  is  not  of  so  much  consequence 
as  valgus. 


192         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

Equinus. —  This  results  from  paralysis  of  the  an-- 
terior  tibial  muscles.  Dorsal  flexion  being  lost,  the  ex- 
tensors can  not  be  fully  drawn  out  except  by  passive  flex- 
ion of  the  tibia  in  walking  with  the  foot  held  straight 
ahead  or  turned  slightly  inwards.  With  the  foot  so  held, 
when  it  is  raised  at  the  end  of  the  step  to  advance  it  for 
the  next  step,  the  toe  drops  to  full  extension,  or  rather  to 
hyperextension,  and  by  dragging  makes  walking  diffi- 
cult. To  avoid  this  embarrassment,  the  foot  is  turned 
outward  and  full  dorsal  flexion  no  longer  takes  place. 
Thus  full  extension  of  the  posterior  muscles,  the  drawing 
of  them  out  to  their  full  length,  never  occurs  and  they 
consequently  become  permanently  shortened.  While  a 
patient  with  paralysis  of  the  anterior  muscles  is  lying 
down  or  sitting  with  the  foot  hanging,  extreme  plantar 
flexion  is  present.  The  anterior  muscles  and  ligaments 
become  more  and  more  stretched  until  the  equinus  is 
marked. 

Whether  valgus  or  varus  co-exists  with  this  deformity 
will  depend  to  a  great  extent  on  whether  the  unpro- 
tected foot  is  used  in  walking  soon  after  the  attack  of 
the  disease.  If  the  influence  of  walking  is  a  minor  fac- 
tor, the  foot  will  become  more  strongly  fixed  in  the 
position  which  it  assumes  when  hanging  free,  and  equino- 
varus  results;  on  the  other  hand,  if  walking  is  under- 
taken early  and  persisted  in,  equino-valgus  will  be  found. 
The  former  deformity,  however,  is  much  more  usual  for 
the  following  reasons :  the  plantar  muscles,  not  having 
the  anterior  muscles  to  extend  them,  suffer  contraction 


INFANTILE    PARALYSIS 


193 


(unless  frequently  and  strongly  stretched  by  the  foot's  be- 
ing used  in  a  valgus  position)  ;  and  by  their  flexion  of  the 
medio-tarsal  joint  they  raise  the  dome,  adduct  the  fore- 
foot, and  help  to  produce  varus.  With  this  position  of 
equino-varus,  the  toes  will  be  extended  at  their  first  inter- 
phalangeal  joints,  because  of  the  contraction  of  the  inter- 
ossei,  which  are  inserted  into  the  extensor  tendons  over 
the  first  phalanx.     The  distal  phalanges  of  the  smaller 


Fig.  (i^  Fig.  68 

Varieties  of  Calcaneus 
In  Fig.  66  the  calcaneum  is  rotated  on  a  transverse  axis  so  that 
the  posterior  surface  of  its  tuberosity  is  walked  upon.     In  Fig.  67 
the  deformity  is  less  marked,  and  in  Fig.  68  the  forefoot  is  flexed 
and  a  cavus  produced  by  the  long  flexors  being  intact. 

toes  will  be  flexed  by  the  shortening  of  the  long  flexor. 
The  contracted  plantar  tissues  may  cause  a  more  marked 
cavus  condition  than  a  varus.  This  cavus,  however,  is 
found  to  be  due  entirely  to  flexion  of  the  forefoot.  If 
the  forefoot  can  be  forced  into  its  normal  position  the 
cavus  disappears. 

Calcaneus. —  With     a     paralysis     of    the     gastroc- 
nemius and  the  soleus,  the  force  of  contraction  of  the 


194 


DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


plantar  muscles  attached  to  the  os  calcis  is  felt  entirely 
in  that  bone,  unprotected  by  the  tendo  Achillis.  Added 
to  the  pull  of  the  plantar  muscles,  is  that  of  the  anterior 
muscles,  especially  of  the  long  extensors.  This  force 
upon  the  os  calcis  tends  to  rotate  it  on  a  transverse  axis 
and  this  rotation  is  further  increased  by  walking,  for  the 


Fig.  6g.     Paralytic  Calcaneus 
Showing  the  transverse  plantar  groove  opposite  the  medio-tarsal 
joint  caused  by  the  folding  together  of  the  forefoot  and  hind-foot. 


impact  of  each  step  is  received  more  and  more  upon  the 
posterior  surface  of  that  bone,  as  the  posterior  extremity 
of  that  bone  and  the  heads  of  the  metatarsals  are  more 
and  more  approximated.  Calcaneus  may  be  accom- 
panied by  very  marked  cavus  or  folding  of  the  forefoot 
so  that  the  foot  of  a  Chinese  lady  is  more  or  less  re- 


INFANTILE    PARALYSIS 


195 


sembled.  It  is  a  matter  under  dispute  whether  or  not 
calcaneus  must  be  the  sequence  of  a  primary  dorsal 
flexion,  which,  in  the  severer  grades,  has,  as  a  conse- 
quence of  walking  and  of  gravity,  given  way  to  a  drop- 
ping down  of  the  forefoot,  helped  sometimes  by  an  intact 
peroneus  longus. 


,^^-^^f£...^.z./> 


PLANTAR  r/ssa£:s 

Fig.  70.    Talipes  Plantaris 

The  anterior  muscles  are  weak  and  the  plantar-flexors  of  the 
forefoot  have  raised  the  dome.  The  ball  of  the  great  toe  is  on  a 
lower  level  than  the  heel. 


Cavus. —  Aside  from  the  condition  of  cavus  which 
may  accompany  other  paralytic  deformities,  there  is  one 
which  is  widely  recognized;  and  although  it  is  probably 
a  result  of  other  than  infantile  paralysis,  being  most 
common  after  the  age  of  childhood,  we  shall  take  this 
opportunity  to  describe  it. 


196  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

Hollow  Claw-foot. —  The  arch  is  increased  and  the 
toes  are  in  a  position  of  dorsal-flexion  at  their  metatarsal- 
phalangeal  joints  and  of  plantar-flexion  at  their  first 
interphalangeal  joints.  Duchenne  attributed  it  to  a 
paralysis  of  the  interossei  and  lumbricales,  which  plantar- 
flex  the  first  phalanges  on  the  metatarsals  and  dorsal- 
flex  at  the  first  interphalangeal  joints ;  and  to  a  paralysis 


T.A.  y  E.LJ). 


Ta,.A 


PAAATTATf  T/SSUES 

Fig.  71.    Talipes  Arcuatus 
The  anterior  muscles  are  weak  and  the  dome  is  raised,  but  the 
forefoot  can  be  dorsal-flexed  to  the  level  of  the  heel. 

of  the  short  flexors  and  of  the  abductor  of  the  great  toe. 
Thus  contraction  of  the  long  flexors  and  extensors  pro- 
duces the  clawed-toes.  Golding-Bird,  however,  attrib- 
uted the  condition  tO'  paralysis  of  the  peronei;  the  un- 
resisted action  of  the  adductors  causing  the  hollow-foot, 
and  the  clawed-toes  resulting  from  the  ineffectuality  of 
the  action  of  the  extensors  on  account  of  the  fact  that  the 


INFANTILE    PARALYSIS  197 

proximal  ends  of  the  first  phalanges  are  held  down  by 
the  contracted  plantar  fascia.  As  this  deformity  is 
usually  associated  with  a  right-angled  contraction  of  the 
tendo  Achillis  and  as  we  have  shown  how  this  contrac- 
tion may  cause  a  hollow-foot,  we  are  inclined  to  believe 
that  the  shortened  heel-cord  may  be  a  causative  factor. 

In  untreated  cases  of  long  standing  those  muscles  which 
show  no  definite  improvement  after  three  or  four  months 
of  treatment,  may  be  condemned  as  permanently  par- 
alyzed. 

CASES    OF    UNDOUBTABLE    PERMANENT    PARALYSIS 

All  the  muscles,  ligaments,  and  fasciae  which  have  been 
retained  in  one  position  for  a  protracted  period,  will  have 
accommodated  themselves  to  that  position.  If  their 
points  of  attachment  have  been  held  nearer  together  than 
normally  they  will  be  contracted  so  that  separation  of  the 
points  of  origin  and  insertion  in  their  usual  extent 
will  be  impossible  without  forcible  stretching  or  division 
of  the  contracted  tissues.  The  points  of  attachment  of 
these  tissues  have  been  brought  nearer  together  by  forces, 
either  intrinsic  or  extrinsic,  by  either  muscular  pull  or 
external  pressure.  An  illustration  of  the  former  in 
causing  contractures  is  seen  in  the  equinus  produced 
when  the  anterior  muscles  of  the  leg  are  paralyzed  and 
the  action  of  the  posterior  muscles  is  unopposed.  Vol- 
untary power  of  reducing  the  equinus  position  is  lost 
and  as  the  calf  muscles  are  not  stretched  to  the  length 
they  have  in  dorsal  flexion  they  become  contracted,  to- 


198 


DISEASES   AND   DEFORMITIES    OF   THE   FOOT 


gather  with  all  the  other  soft  structures  which  are  held 
in  a  shortened  position. 

Furthermore,  the  plantar  muscles  will  hold  the  fore- 
foot flexed  at  the  medio-tarsal  joint  since  they  are  un- 
opposed by  the  anterior  muscles,  and  a  cavity  deformity 


Tf^.A: 


Fig.  72,  Paralysis  of  the  Anterior  Muscles 
The  foot  is  drawn  into  the  position  of  equinus.  The  dome  is 
raised,  owing  to  the  unresisted  action  of  the  plantar-flexors  of  the 
forefoot  and  contraction  of  the  plantar  fascia.  The  toes  are  not 
more  flexed  because  the  interossei,  inserted  into  the  tendons  of 
the  long  extensors,  are  intact.  Walking  also  helps  to  keep  the  toes 
extended. 


will  be  added  to  the  equinus.  There  will  also  be  flexion 
deformity  at  the  metatarsal-phalangeal  joints;  but  the 
flexion  deformity  will  not  have  taken  place  at  the  inter- 
phalangeal  joints  because  the  interossei  muscles,  through 
their  attachments  to  the  long  extensor  tendons  over  the 


INFANTILE    PARALYSIS  1 99 

first  phalanges,  will  keep  intact  some  power  of  extension 
at  these  joints. 

•  Whether   an   external    force,   as   weight-bearing,    in- 
creases or  decreases  a  deformity  of  the  foot  must  depend 
on  its  direction,  strength,  and  duration;  so  the  amount 
of  cavus  deformity  and  of  deformity  of  the  toes  in  a 
F.LJ) 


Fig.  t>).    Paralysis  of  the  Tendo  Achilus  and  the 
Anterior  Muscles 
The    sound,    long   flexors   flex   the    forefoot,    contraction   of   the 
plantar   tissues    approximate   the   calcaneum   and   the   metatarsals; 
thus  a  cavus  is  produced. 

case  with  the  above  mentioned  paralysis,  will  be  influ- 
enced by  the  amount  and  manner  of  the  use  to  which  the 
foot  is  put. 

If  all  the  muscles  passing  over  the  ankle  are  paralyzed 
and  only  the  plantar  muscles  are  left  intact,  there  will 
be  added  a  rotation  of  the  os  calcis  on  a  transverse  axis, 
so  that  its  tuberosity  will  be  moved  downward  and  for- 


200         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

ward;  and  its  anterior  extremity  upward,  and,  at  first, 
forward,  and  then  backward.  This  is  brought  about 
through  the  absence  of  the  calf -muscles'  offering  a  point 
of  resistance  by  holding  the  os  calcis  firm,  when  the 
plantar  muscles  contract;  and  consequently  at  each  con- 
traction of  these  plantar  muscles  the  force  is  not  firmly 
resisted  by  the  os  calcis  and  the  bone  gives  in  the  di- 


Fig.  74.  Paralysis  of  the  Posterior  and  the  Plantar  Muscles 
The  foot  is  drawn  into  the  position  of  dorsal  flexion.  In  walk- 
ing the  heel  is  presented  tO'  the  ground  in  advance  of  the  toes  and 
as  the  impact  of  the  calcaneum  is  received  more  and  more,  as  de- 
formity progresses,  on  the  posterior  tuberosity  of  that  bone,  a  cal- 
caneous  results. 

rection  of  this  rotation.  Thus  a  calcaneus  is  produced 
which,  added  to  the  flexion  of  the  forefoot,  forms  a 
marked  cavus  or  hollow-foot.  With  this  flail  ankle,  the 
foot,  in  walking,  will  take  a  position  of  eversion;  and  if 
much  used  will  tend  more  and  more  to  flatten  the  dome, 
but  this  force  will  not  prevent,  although  it  may  delay,  the 
calcaneo-cavus. 


INFANTILE    PARALYSIS 


201 


If  the  posterior  muscles  are  alone  paralyzed,  the  os 
calcis  will  suffer  the  rotation  as  described  above  and  the 
forefoot  will  be  drawn  up  into  exaggerated  dorsal  flexion. 
Flexion  will  not  only  be  pronounced  at  the  ankle  joint,  but 
there  will  be  extension  at  the  medio-tarsal  joint,  and 
the  patient  will  walk  upon  the  heel. 

If  all  the  posterior  muscles   are  paralyzed,   and   the 


Fig.  75.  Paralysis  of  All  the  Muscles  Except  the  Gastroc- 
nemius AND  the  SoLEUS 
With  the  tendo  Achillis  normal  the  heel  is  raised,  but  aii  equinus 
of  the  foot  is  not  produced  because  there  are  no  muscles  to  flex 
the  forefoot  and  because  use  of  such  a  foot  tends  to  lower  the 
dome,  to  extend  the  medio-tarsal  joint. 

plantar  muscles  as  well,  the  os  calcis  will  not  be  rotated 
and  the  toes  will  be  held  in  extension.  There  will  be 
dorsal  flexion  at  the  medio-tarsal  joint  and  the  dome 
will  be  flattened. 

When  the  tibialis  anticus  alone  is  paralyzed,  the  foot 
will  be  drawn  into  eversion  whenever  dorsal  flexion  takes 
place;  and  in  standing,  the  inner  border  of  the  foot 
will  fall  into  a  position  of  valgus,  especially  marked  if 


202  DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

there   is   paralysis  of   the  tibiaHs   posticus   accompany- 
ing it, 

TREATMENT 

Reduction  o£  Deformities. —  Whether  our  object  is 
to  discharge  the  patient  wearing  braces  or  whether  we  in- 
tend to  attempt  the  restoration  of  power  in  the  control 
of  joints  by  muscle  transplantation,  or  to  support  them  by 
the  use  of  artificial  ligaments  or  by  arthrodesis  we  plan  to 
immobilize  them,  the  first  concern  of  the  surgeon  must 
be  the  reduction  of  deformities.  Reduction  of  deformity 
may  be  undertaken  by  manual  or  instrumental  force, 
or  by  open  or  subcutaneous  cutting  operations.  Most 
contractures  about  the  foot  can  be  made  to  yield  to 
stretching,  without  the  use  of  an  anesthetic,  if  the  forces 
are  correctly  and  repeatedly  applied  and  the  improvement 
constantly  maintained.  To  be  painless  and  at  the  same 
time  efficient,  the  forces  must  be  applied  with  such  exacti- 
tude and  perfect  control  that  special  apparatus  is  generally 
necessary. 

Instrumental  Stretching. — In  the  hands  of  the  ortho- 
pedic surgeon,  Shaffer's  antero-posterior  and  lateral 
traction  shoes  will  give  most  satisfactory  results.  Special 
mechanical  knowledge  and  an  abundance  of  patience,  to- 
gether with  the  absolute  confidence  and  cooperation  of 
the  patient,  are  necessary;  and  therefore  these  appara- 
tuses have  never  been  very  popular  with  the  general 
surgeon.  A  keen  knowledge  of  mechanics  is  absolutely 
essential  for  the  successful  use  of  orthopedic  apparatus. 


INFANTILE    PARALYSIS  2O3 

Without  this  knowledge  the  surgeon  had  better  content 
himself  with  the  knife  and  plaster-of-Paris.  Therefore, 
I  am  persuaded  that  it  is  advisable  for  me  to  give  but  a 
short  description  of  the  lateral-traction-shoe  and  that  is 
only  for  those  who  are  or  might  become  orthopedic 
surgeons. 

Lateral-Traction  Shoe. —  The  lateral-traction  ap- 
paratus is  based  upon  the  three  varieties  of  rotation  on 
the  three  axes  of  movements  of  the  foot.  It  consists  of 
a  calf  band,  A,  to  which  is  attached  a  single  upright,  A'. 
This  upright  is  always  placed  on  the  side  toward  which 
the  deformity  looks;  in  varus  on  the  inside,  in  valgus 
on  the  outside  of  the  leg,  the  instrument  being  a  pusher. 
At  a  point  just  above  the  axis  of  motion  of  the  ankle- 
joint,  are  placed  a  lateral  joint,  C,  which  is  acted  upon 
by  a  hinged  lever  and  screw;  and  O,  an  arm,  which 
pushes  the  lower  part  of  the  apparatus  toward  the  de- 
formity to  any  desired  extent.  The  distal  end  of  this 
arm  is  free,  and,  as  the  arm  is  turned  away  from  the 
deformity  by  key  B',  the  foot  part  of  the  apparatus  takes 
any  lateral  position  required.  This  lateral  hinge,  with 
its  lever  and  screw,  is  intended  to  meet  especially  the 
inversion  of  the  os  calcis.  When  traction  is  applied,  it 
antagonizes  the  tibialis  posticus  muscle  contraction  as 
well  as  the  shortening  of  the  internal  lateral  ligament. 
Just  below  the  hinged  lever  and  screw  is  an  antero-pos- 
terior  joint,  E,  a  worm  and  screw  controlled  by  the 
key  E'.  With  this  any  degree  of  flexion  and  extension 
may  be  obtained.     Still  lower  and  acting  upon  the  an- 


204 


DISEASES    AND    DEFORMITIES    OF    THE    FOOT 


terior  part  of  the  foot-plate  (which  is  divided  trans- 
versely at  a  point  corresponding  to  the  medio-tarsal 
joint)  is  the  traction  rod  placed  upon  the  inner  side  of 
the  apparatus  and  moving  in  the  cylinder  F.     It  is  con- 


FiG.  76.    Shaffer's  Lateral  Traction  Shoe 
The  movements  about  the  three  chief  axes  of  the  foot  are  con- 
trolled by  the  three  keys.    A  full  description  is  given  in  the  text. 

trolled  by  the  key  G'.  H  is  the  heel-cup,  through  the 
openings  in  which,  X,  are  passed  the  ends  of  the  as- 
tragalar  strap.  The  outer  part  of  the  heel-plate  is  ex- 
tended quite  well  forward  to  form  a  resistance  to  the 
rotating  movement  imparted  to  the  foot  by  the  traction 


INFANTILE    PARALYSIS  20$ 

rod  G.  The  inner  border  of  the  foot-plate  is  curved 
over  the  dorsum  of  the  foot,  J,  in  order  to  grasp  it  as 
it  moves  from  the  center  of  motion  at  the  outer  border 
of  the  foot.  The  heel-plate  part  of  the  heel-cup  has  the 
semicircular  opening  to  permit  the  descent  of  the  heel 
when  traction  is  applied,  the  same  as  in  the  antero-pos- 
terior  shoe. 

Determination  of  Obstruction. —  It  is  worthy  of 
remark,  that  as  exact  a  determination  as  is  possible,  as 
to  what  tissues  are  obstructing  correction,  should  be 
made.  The  X-ray  will  assist  in  demonstrating  the  ex- 
tent of  any  bony  obstruction,  but  the  hands  of  the  sur- 
geon are  of  the  first  importance.  The  resistance  caused 
by  bone  is  of  a  decidedly  different  "  feel "  from  that  due 
to  ligament  or  muscle.  It  must  be  borne  in  mind  that 
the  movement  allowed  by  the  removal  of  one  obstruction 
may  be  immediately  blocked  by  another  tissue  which  is 
shortened  or  otherwise  abnormal.  Thus  an  operator 
may  be  greatly  disappointed  at  finding  that  a  simple  ten- 
otomy, while  sufficient  to  remove  all  immediate  obstruc- 
tion to  correction,  has  simply  served  to  bring  into  action 
other  obstructions. 

It  is  worth  while  to  spend  much  time  and  effort  in 
trying  to  lengthen  soft  tissues  by  force,  applied  with  the 
hand  or  wrench;  but  bony  deformities  will  yield  only 
to  constant  pressure  and  friction,  and  to  the  chisel. 

Recovery  of  Muscles. —  After  the  restoration  of  the 
foot  to  its  normal  position,  the  bones  being  in  their  nor- 
mal relations  to  each  other,  it  should  be  maintained  thus 


206         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

for  a  sufficient  length  of  time  to  assure  the  surgeon  that 
all  possible  recovery  of  muscular  power  has  taken  place. 
Even  though  a  muscle  has  been  out  of  use  for  some 
years,  it  may  yet  enjoy  a  return  of  power  if  the  oppor- 
tunity is  given.  That  is  to  say,  although  the  cells  in  the 
anterior  horns,  which  supply  the  muscle,  were  attacked 
by  the  original  disease,  they  may  have  recovered  but  are 
unable  to  cause  contraction  of  the  muscle  because  the 
muscle  is  so  stretched.  It  is  impossible  to  say  in  any 
given  case,  how  long  a  time  should  be  given  to  Nature 
to  show  a  return  of  muscular  power.  As  a  rule,  if  a 
muscle  is  kept  constantly  in  the  best  position  for  it  to 
contract  for  five  or  six  months,  and  if  at  the  end  of  that 
time  there  is  no  apparent  return  of  nervous  control,  it 
may  be  condemned  as  permanently  paralyzed. 

Braces. —  During  this  period  of  giving  Nature  an 
opportunity,  braces  should  be  applied.     The  design  of 


Fig.  •]•].    Right- Angle  Stop  at  Ankle- Joint 
With  this  stop  plantar  flexion  beyond  a  right  angle  is  prevented. 
It  is  to  be  used  in  paralysis  of  the  dorsal-flexors. 

the  brace  should  be  such  as  to  protect  the  paralyzed  mus- 
cles from  being  stretched  by  the  sound  muscles.  If  the 
anterior  muscles  are  paralyzed  the  brace  must  be  so  con- 
structed as  to  prevent  plantar  flexion  beyond  a  right 


INFANTILE    PARALYSIS 


207 


angle.  If  the  posterior  muscles  are  paralyzed,  dorsal 
flexion  must  be  prevented  beyond  a  right  angle.  The 
easiest  way  to  make  the  joint  of  the  brace  meet  these 
requirements,  is  to  have  a  tongue  extend  beyond  the 
joint  with  a  peg  to  stop  motion  in  the  direction  of  the 
healthy  muscles. 


Fig.  78.    Reverse- Stop  at  Ankle- Joint 
With  this  stop  dorsal-flexion  is  limited  to  a  right  angle  with  the 
leg.     It  is  indicated  in  paralysis  of  the  plantar-flexors. 


Fig.  'jg.  A  Stop- Joint  Allowing  a  Few  Degrees  of  Motion  Only 
This  is  of  use  when  extensive  paralysis  is  present.  It  facilitates 
walking  by  permitting  the  body  to  be  brought  over  the  foot  while 
it  is  flat  upon  the  ground.  If  there  is  no  movement  at  this  joint, 
the  heel  must  be  raised  as  soon  as  the  vertical  is  reached,  which 
markedly  embarrasses  the  walk. 

The  brace  may  be  secured  to  the  outside  of  the  shoe 
or  it  may  be  made  with  a  foot-piece  and  be  worn  inside 
of  the  shoe.  It  will  be  found  easier  to  fit  the  brace  if  it 
is  made  to  go  outside  of  the  shoe  and  though  that  shoe 
will  always  have  to  be  worn,  unless  other  braces  are 
made  and  fitted  to  other  shoes,  we  should  advise  that 


208 


DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


the  surgeon  of  little  experience  in  such  matters  use  the 
outside  brace.  The  inside  brace,  if  not  accurately  fitted, 
is  likely  to  be  uncomfortable;  and  many  patients  have 
discontinued  treatment,  when  the  principle  of  the  brace 
was  perfectly  correct,  because  they  despaired  of  ever 
being  able  to  obtain  an  accurate  fit. 

The  joint  of  the  brace  must  not  be  too  high ;  this  fault 


Fig.  8o.  Location  of  Ankle-Brace  Joint 
Illustrating  the  necessity  of  the  joint  of  a  brace  being  below  the 
ankle-joint:  X  represents  the  joint  of  the  brace,  if  within  the  arc 
of  movement  at  the  ankle  as  in  A,  no  interarticular  pressure  will 
be  caused  by  motion,  while  if  the  joint  of  the  brace  is  above  the 
ankle-joint,  as  in  B,  motion  in  either  dorsal  or  plantar  flexion  must 
cause  interarticular  pressure. 

is  very  frequently  made  by  those  unfamiliar  with  physi- 
ological mechanics.  The  center  of  the  joint  should  be 
opposite  the  tip  of  the  external  malleolus,  or  even  a  little 
lower.  The  side  bars  should  lie  close  to  the  leg  and  not 
stand  away  a  quarter  of  an  inch  or  so,  and  this  fit  should 
be  just  as  accurate  over  the  malleoli.  If  valgus  is  as- 
sumed upon  weight-bearing,  a  pad  should  be  placed  on 
the  outer  side,  low  down,  so  as  to  hold  the  tarsal  bones 


INFANTILE   PARALYSIS  209 

in  their  proper  position.  If  varus  is  assumed  under  these 
circumstances,  the  pad  should  be  placed  on  the  inner  side. 
The  pad  is  not  to  push  over  the  ankle,  the  prominent 
malleolus,  as  some  seem  to  suppose. 

Wedge  Sole. —  When  the  paralysis  is  very  slight 
and  confined  to  one  or  two  muscles,  as  the  tibialis  anticus 
or  the  peronei,  it  may  be  necessary  only  to  apply  a  wedge 
to  the  shoe,  such  as  was  described  under  congenital  club- 
foot; or  a  steel  insole  can  sometimes  be  fitted  to  meet 
all  requirements. 

When  one  is  satisfied  that  the  remaining  paralysis  is 
permanent,  consideration  may  be  given  to  the  possibility 
of  some  operation  relieving  the  patient  from  the  neces- 
sity of  wearing  a  brace  for  the  rest  of  his  life. 

Tendon  Transplantation.- — This  is  very  successful 
if  correctly  planned  and  properly  executed.  The  plan- 
ning must  provide  for  the  substitution  of  sufficient  new 
muscular  force  to  take  the  place  of  the  paralyzed  mus- 
cles, without  too  great  weakening  of  movements  in  other 
directions ;  and  the  execution  of  the  operation  must  be 
done  with  the  most  careful  transposition  of  the  tendon, 
providing  as  direct  a  line  as  possible  to  the  new  insertion, 
arranging  the  bed  for  the  tendon  so  that  it  may  move 
freely  and  not  be  held  by  adhesions,  and  exhibiting  a 
perfect  aseptic  technique.  The  after  treatment  is  of  an 
importance  second  only  to  the  operation  itself :  immobi- 
lization for  four  weeks  followed  by  gentle  massage  and 
active  and  passive  movements  for  several  months. 

The  condition  in  which  the  tibialis  anticus  is  the  only 


2IO         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

muscle  paralyzed,  is  the  most  promising  for  this  oper- 
ation. The  muscle  to  be  transplanted  is  the  extensor 
longus  pollicis.  Three  very  small  incisions  are  all  that 
are  required,  though  one  long  curved  incision  may  be 
used.  The  tendon  of  the  long  flexor  is  divided  over  the 
middle  of  the  metatarsal,  the  distal  end  secured  by  silk 
or  linen  suture  to  the  tendon  of  the  flexor  longus  digi- 
torum  going  to  the  second  toe,  and  the  proximal  end 
drawn  out  through  an  incision  made  over  the  ankle  at 
the  forward  turn  made  by  the  tendon  as  it  goes  forward 
to  the  great  toe.  An  incision  is  then  made  over  the 
tuberosity  of  the  scaphoid,  a  tunnel  made  to  the  incision 
above,  and  the  tendon  drawn  down  through  this  and 
sutured  with  silk  to  the  periosteum  or  drawn  through  a 
hole  drilled  in  the  bone,  and  then  sutured.  The  tendon 
should  be  drawn  taut  before  it  is  sutured,  with  the  foot 
in  dorsal  flexion  to  eighty-five  degrees  and  in  slight  in- 
version. The  position  of  the  foot  is  retained  in  a  plas- 
ter-of- Paris  dressing  for  four  weeks.  A  brace  is  then 
worn  for  six  months  to  prevent  the  extremes  of  motion. 
A  night  shoe  is  also  prescribed,  and  massage  given  daily. 
It  may  be  necessary  for  the  patient  to  wear  a  wedge  on 
the  inner  side  of  the  sole  after  the  brace  is  discarded. 

This  operation  may  sometimes  be  supplemented,  when 
eversion  is  pronounced,  by  also  transplanting  a  slip  from 
the  extensor  longus  digitorum  to  the  scaphoid.  If  this 
is  done  the  distal  extremity  of  the  extensor  longus  digi- 
torum is  secured  to  the  periosteum  of  the  metatarsal. 
The  tendon  of  the  peroneus  longus  may  also  be  used  tO' 


INFANTILE    PARALYSIS 


211 


reenforce  the  flexor  longus  pollicis.  This  is  done  by 
dividing  it  over  the  head  of  the  os  calcis,  drawing-  it  out 
through  an  incision  two  inches  above  the  tip  of  the  ex- 


FiG.  8i.  Night-Shoe 
An  apparatus  for  retaining  the  foot  in  the  right-angled  position 
while  the  patient  is  in  bed.  The  heel-strap,  secured  to  buckles  on 
the  bottom  of  the  foot-plate,  passes  over  the  bar  at  the  toe  and 
down  the  sides  of  the  foot  and  around  the  heel.  The  astragalar 
strap  passes  over  the  instep  to-  hold  the  heel  against  the  foot-plate. 

ternal  malleolus,  and  then  passing  it  through  a  tunnel 
downward  and  forward,  across  the  inner  surface  of  the 
tibia  and  above  the  internal  malleolus,  to  the  scaphoid. 
Where  the  condition  presents  a  paralysis  of  the  gas- 


212  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

trocnemius  and  the  soleus,  muscles  from  each  side  of 
the  tendo  AchilHs  may  be  taken  and  secured  either  to  the 
tendon  itself  or  directly  into  the  os  calcis.  Both  pero- 
neals and  the  tibialis  posticus  and  the  flexor  longus  digi- 
torum  are  all  accessible.  My  personal  experience  with 
this  operation  has  not  been  successful.  It  is  easy  to  ob- 
tain good  active  motion  in  plantar  flexion  at  the  ankle 
joint;  but  as  soon  as  this  motion  is  attempted  while  the 
foot  is  weight-bearing,  the  insufficiency  even  of  all  these 
muscles  as  compared  to  the  two  muscles  they  try  to  sup- 
plant, becomes  evident,  and  instead  of  becoming  stronger 
with  use,  as  one  might  expect,  they  become  weaker. 
Moreover,  in  this  operation  one  is  using  muscles  which 
can  ill  be  spared  from  their  normal  functions.  Others 
have  made  artificial  tendons  from  the  hamstring  mus- 
cles to  the  OS  calcis  and  have  reported  good  results. 
This  operation  I  have  never  tried. 

Silk  Ligaments. —  Where  a  flail  joint  exists,  silk 
ligaments  may  be  inserted  to  prevent  foot-drop.  This 
will  prevent  the  dragging  of  the  toes  and  greatly  assist 
in  walking.  The  operation  is  a  simple  one.  Number  i6 
or  1 8  silk  is  used.  It  is  best  to  boil  it  first  in  bichloride 
for  an  hour  and  then  in  plain  water  for  fifteen  minutes 
and  dip  in  boiling  paraffin  shortly  before  it  is  used.  Two 
ligaments  are  placed,  each  having  two  strands  of  the 
silk.  One  extends  from  the  cuboid,  under  the  annular 
ligament,  to  the  tibia  at  a  point  two  inches  above  its 
articular  surface  for  the  astragalus.  The  other  passes 
from  the  scaphoid,  also  beneath  the  annular  ligament,  to 


INFANTILE    PARALYSIS  213 

the  same  point  on  the  tibia.  The  bone  insertions  may 
be  made  through  drill  holes.  By  passing  under  the  an- 
nular ligament,  the  new  ligaments  will  not  be  raised  up 
prominently  at  the  ankle  when  attempts  are  made  at 
dorsal  flexion.  All  knots  should  be  in  positions  where 
they  can  be  well  buried  in  subcutaneous  tissue. 
■  In  the  insertion  of  silk  as  ligaments,  Ryerson  was,  I 
believe,  the  first  to  place  them  in  the  tendon-sheaths  of 
the  paralyzed  muscles  which  they  are  to  supplant.  This 
is  undoubtedly  a  great  advance  in  the  technique.  Allison 
has  added  some  ingenious  details :  in  foot-drop  he  uses 
one  continuous  strand,  passing  it  through  a  drilled  chan- 
nel in  the  tarsus  and  running  one  end  up  the  sheath  of 
the  peroneus  tertius  and  the  other  up  the  sheath  of  the 
tibialis  anticus,  securing  both  ends  high  up  on  the  tibia 
to  its  periosteum;  to  prevent  calcaneous  deformity  in 
paralysis  of  the  gastrocnemius  and  soleus,  he  drills  two 
holes  from  the  plantar  surface  of  the  calcaneum  upward 
to  either  side  of  the  tendo  Achillis  and  threads  the  silk 
through  them,  bringing  the  loop  taut  around  the  heel 
and  securing  the  ends  to  the  tibia  after  passing  them 
up  through  the  sheath  of  the  tendon. 

Astragalectomy. —  Whitman's  astragalectomy,  which 
he  devised  for  the  treatment  of  calcaneus,  is  excellent 
also  in  cases  of  paralysis  where  all  or  nearly  all  the  mus- 
cles crossing  the  ankle-joint  are  powerless.  While  this 
operation  allows  of  some  movement,  it  prevents  the  ex- 
tremes of  either  flexion  or  extension  and  thus  facilitates 
walking,  making  it  as  easy  as  does  an  ankle  brace  which 


214         DISEASES   AND    DEFORMITIES    OF   THE   FOOT 

allows  of  slight  motion.  Moreover,  it  firmly  holds  the 
foot  in  the  antero-posterior  plane.  It  also  increases 
the  development  of  the  foot,  since  it  is  used  quite  freely. 
Whether  performed  for  calcaneus  or  for  a  flail  ankle- 
joint,  the  operation  is  practically  the  same.  The  steps 
of  the  operation  are  as  follows :  "  An  Esmarc  bandage 
■having  been  applied,  an  incision  is  made  from  a  point 
about  one  inch  above  the  external  malleolus  midway  be- 
tween it  and  the  tendo  Achillis,  passing  downward  to  the 
attachment  of  the  tendo  Achillis,  forward  below  the  ex- 
tremity of  the  malleolus  and  over  the  dorsum  of  the 
foot  to  the  external  surface  of  the  head  of  the  astragalus. 
The  sheaths  of  the  peroneal  tendons  which  are  exposed 
at  once  are  opened,  the  tendons  divided  below  the  malleo- 
lus and  drawn  backward.  One  next  divides  the  bands 
of  the  external  lateral  ligament,  and  the  foot  being  some- 
what adducted,  the  interosseous  ligament  is  divided.  On 
further  inversion,  the  tissues  being  retracted,  one  may 
with  scissors  free  the  head  of  the  astragalus  from  its  at- 
tachments to  the  navicular,  and  forcibly  twisting  it  out- 
ward, break  off  the  cartilaginous  margin  to  which  the 
internal  and  posterior  ligaments  that  can  not  be  reached 
are  attached.  One  then  prepares  the  new  articulation. 
A  thin  section  is  removed  from  the  lateral  aspects  of  the 
adjoining  os  calcis  and  cuboid  bones,  and  from  the  in- 
ternal surface  of  the  external  malleolus,  which  may  be 
further  shaped  to  secure  accurate  apposition.  The  same, 
but  more  difficult,  procedure  is  undertaken  on  the  inner 
side.     One  thoroughly  separates  the  internal  lateral  liga- 


INFANTILE   PARALYSIS  21 5 

merit  from  the  malleolus  in  order  to  permit  complete 
backward  displacement,  then  removes  the  cartilage  from 
its  inner  surface.  With  a  periosteal  elevator  the  strong 
inferior  calcaneo-navicular  ligament  is  detached  suffi- 
ciently to  permit  the  malleolus  to  sink  in  behind  or 
slightly  to  overlap  the  navicular.  The  two  peroneal  ten- 
dons, thoroughly  freed  from  their  attachments  to  the 
fibula,  are  then  passed  through  the  base  of  the  tendo 
Achillis  from  within  outward  and  are  sutured  to  it  and 
to  the  periosteum  of  the  os  calcis  as  well,  at  a  sufficient 
tension  to  hold  the  foot  in  moderate  plantar  flexion. 
The  tendo  Achillis  is  sometimes  overlapped  and  sutured 
as  an  aid  in  restraining  deformity.  The  malleoli  are 
then  forced  forward  and  accurately  adjusted  to  the  new 
articulation  and  the  wound  closed  with  catgut,  reenforced 
with  several  silk  sutures.  The  foot,  carefully  supported 
in  its  attitude  of  backward  displacement  and  moderate 
plantar  flexion,  is  thickly  covered  with  sterilized  sheet, 
wadding  and  fixed  by  a  light  plaster  bandage,  particular 
care  being  taken  to  exert  only  the  slightest  constriction. 
The  leg  is  then  brought  to  a  right  angle  with  the  thigh 
and  the  plaster  bandage  is  continued  over  the  thigh,  reen- 
forced by  a  band  of  steel  in  the  popliteal  region.  The 
limb  is  suspended  for  several  days  or  a  week,  the  aim 
being  to  relax  tension  and  to  lessen  the  congestion.  The 
plaster  bandage  fixing  the  limb  in  flexion  at  the  knee 
remains  for  several  weeks  until  immediate  repair  is  com- 
plete, a  section  being  removed  over  the  wound  to  permit 
inspection  at  the  end  of  a  week.     It  is  then  replaced  by 


2l6  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

one  that  reaches  only  to  the  knee,  holding  the  foot  in 
moderate  plantar  flexion,  the  sole  being  made  level  by 
the  insertion  of  a  piece  of  cork.  The  plaster  support  is 
worn  for  about  six  months,  the  longer  the  better,  since 
the  patient  must  bear  weight  on  the  front  of  the  foot. 
Success  in  this  treatment  is  directly  dependent  upon  the 
accuracy  with  which  its  details  are  carried  out.  The 
most  important  of  these  is  secure  fixation  in  complete 
backward  displacement." 


CHAPTER  IX 
TUBERCULOUS  AND  GONORRHEAL  DISEASE 

TUBERCULOUS    DISEASE    OF    THE    FOOT 

The  primary  focus  may  be  in  the  tibia,  fibula,  one  of 
the  tarsal  bones,  or  in  the  synovial  membrane.  Clinically 
it  is  usually  found  to  be  limited  to  one  bone  or  to  involve 
one  or  more  joints  together  with  the  synovial  membrane. 
The  tendon  sheaths  may  be  infected,  especially  that  of 
tibialis  anticus,  from  their  insertion  into  an  infected 
bone.  The  order  of  frequency  in  which  the  bones  were 
attacked  in  1231  cases  collected  by  Whitman,  were:  cal- 
caneum,  astragalus,  cuboid,  scaphoid  and  metatarsals, 
cuneiform  bones,  malleoli,  phalanges.  The  calcaneum 
and  the  astragalus  are  primarily  infected  much  more  than 
any  of  the  other  bones. 

The  etiology  and  pathology  are  the  same  as  bone  tu- 
berculosis elsewhere. 

Diagnosis. —  The  history  will  be  that  of  a  limp  with 
more  or  less  pain,  especially  at  night,  alterations  in  the 
contour  of  the  foot  and  sometimes  sinus  formation.  In 
children  it  is  usually  the  limp  for  which  consultation  is 
sought. 

Limp.  —  At  the  beginning  this  will  be  intermittent. 
The  infected  foot  will  unconsciously  be  favored  in  such 
a  way  as  to   relieve  the   infected  areas   from  weigh t- 

217 


2l8  DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

bearing  and  from  movement.  Thus,  if  the  focus  is  in 
the  astragalus  or  in  the  os  calcis,  the  foot  will  be  used  in 
the  position  of  slight  equinus;  if  the  medio-tarsal  joint 
is  the  location  of  the  infection,  the  deformity  will  be  that 
of  abduction,  resembling  that  of  valgus ;  and  if  the  focus 
is  in  the  forefoot,  the  child  will  walk  on  the  heel. 

Pain  will  not  be  a  prominent  symptom  during  the  early 
stages,  but  later,  especially  in  adults,  it  may  be  severe.  In 
children  the  pain  may  be  enough  to  disturb  sleep  and  to 
cause  the  patient  to  desist  from  romping  as  much  as  usual. 
There  is  little  of  value  as  a  help  in  diagnosis,  in  the 
designated  site  of  the  pain.  It  may  be  along  the  inner 
or  outer  side  of  the  foot.  Sometimes  pressure  over  the 
site  of  the  infection  will  produce  pain,  but  the  absence 
of  such  a  painful  spot  is  of  little  or  no  value.  The 
character  of  the  pain  is  not  distinctive  of  this  disease. 
In  adults,  when  the  medio-tarsal  joint  is  involved,  the 
pain  may  resemble  very  closely  that  accompanying  flat- 
foot  ;  a  strained,  sore,  aching  feeling  rather  than  a  sharp, 
severe,  acute  pain. 

Contour. —  In  the  earliest  stages  even,  a  careful  ob- 
server, on  comparing  the  two  feet,  will  note  differences 
in  them.  Depressions  in  the  normal  foot  will  be  filled 
in,  partially  or  completely,  in  the  other.  If  the  synovial 
membrane  is  infected  early,  there  will  be  a  puffy  appear- 
ance wherever  the  infected  membrane  is  not  confined 
securely  by  the  over-lying  structures;  as  on  each  side 
of  the  tendo  Achillis,  below  and  in  front  of  the  malleoli, 
over  the  calcaneo-cuboid  joint,  or  the  astragalo-scaphoid 


TUBERCULOUS   AND   GONORRHEAL  DISEASE  219 

joint,  or  in  front  of  the  ankle  on  either  side  of  the  ex- 
tensor tendons.  The  atrophy  of  the  calf-muscles  is  an 
early  sign,  but  in  the  early  stages  is  not  recognizable 
except  by  the  use  of  the  tape-measure. 

The  consistence  of  the  swelling  will  differentiate  be- 
tween bony  enlargement,  induration  of  the  soft  parts, 
synovitis  and  abscess  formation.  That  is  to  say  an  at- 
tempt should  always  be  made  to  make  such  a  differenti- 
ation, but  experience  alone  can  teach  the  comparative 
points  in  density,  in  fluctuation  and  in  "  feel." 


Fig.  82.    Tuberculous  Foot 
This  drawing,   from  a  photograph,   shows  the  fusiform  enlarge- 
ment, pointing  of  the  toes  and  the  equinus  position. 

Deformity. —  If  the  ankle  joint  is  infected,  there  will 
gradually  be  assumed  a  position  of  equinus;  if  the  cal- 
caneo-astragaloid  joint,  a  position  of  eversion;  and  if 
the  medio-tarsal  point,  especially  the  astragalo-scaphoid 
joint,  a  position  of  abduction.  With  the  increase  of  the 
amount  of  tissue  involved,  the  entire  ankle  and  foot  be- 
come involved,  fusiform  in  shape,  with  toes  pointed 
downward  and  slightly  outward;  and  the  possible  ap- 
pearance of  sinuses,  in  almost  any  location,  will  complete 
the  picture. 


220  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

When  one  malleolus  is  attacked,  it  may  be  so  enlarged 
as  to  give  the  foot  the  appearance  of  having  been  badly 
treated  after  a  fracture.  The  foot  seems  to  be  dislo- 
cated at  the  ankle  in  the  opposite  direction.  As  long  as 
the  ankle  joint  is  free  of  infection  there  will  be  no  mus- 
cular spasm  associated  with  its  movements.  Frequently 
pressure  over  the  malleolus  will  give  pain. 

Heat. —  Heat  will  be  present  during  the  activity  of  the 
disease.  It  is  best  determined  by  first  laying  the  hand 
on  the  sound  foot  until  its  temperature  is  determined,  as 
compared  with  the  temperature  of  the  hand;  and  then 
placing  the  hand  on  the  suspected  foot  and  noting  any 
difference  in  temperature.  If  one  becomes  adept  in  this 
examination  for  slight  differences  in  the  temperature  of 
the  two  feet,  he  will  have  an  excellent  aid  to  the  de- 
termination of  the  efficiency  of  any  treatment  being  pur- 
sued. Redness  is  not  present  except  at  some  point  in 
advance  of  the  opening  of  an  abscess.  The  superficial 
veins  may  be  much  more  marked  than  in  the  other  foot. 

Muscular  Spasm.  —  This  will  invariably  be  present 
whenever  a  joint  becomes  involved.  Any  movement, 
active  or  passive,  of  such  a  joint  will  elicit  this  spasm. 
Whether  the  spasm  occurs  at  the  beginning  of  move- 
ment, or  not  until  the  normal  limitations  of  movement 
at  that  joint  have  been  reached,  will  depend  upon  the 
exact  location  of  the  infected  area  and  its  extent.  If 
this  area  is  extensive,  there  will  be  no  movement  in  the 
joint,  it  will  be  absolutely  immobilized  by  the  muscular 
spasm;  if  this  area  is  very  limited,  movements  may  be 


TUBERCULOUS   AND    GONORRHEAL   DISEASE  221 

free  until  the  limitations  are  approached,  when  they  will 
be  found  to  be  halted  before  they  are  in  the  normal  foot ; 
the  range  of  motion  is  shortened.  This  spasm  is  the 
same  involuntary  protection  of  a  diseased  condition,  or 
an  injury,  which  is  found  in  so  many  instances.  The 
diagnostic  value  of  this  spasm  was,  I  believe,  not  fully 
recognized  until  studied  by  the  orthopedic  surgeon. 
To-day  the  general  surgeon,  in  a  case  of  appendicitis  for 
instance,  is  often  guided  more  by  the  spasm  than  by  any 
other  one  sign  or  symptom. 

In  examining  a  joint  for  muscular  spasm,  it  is  neces- 
sary that  the  examiner  be  ready  and  able  to  recognize  the 
slightest  restriction  to  movement,  its  sharp,  sudden  ap- 
pearance, its  muscular  rather  than  bony  "  feel,"  and  the 
invariableness  with  which  this  spasm  always  appears 
when  that  particular  angle  of  movement  is  reached. 
There  is  no  better  indication  of  the  progress,  or  the  lack 
of  progress,  being  made  in  the  treatment  of  tuberculous 
arthritis,  than  the  increase  or  decrease  of  the  muscular 
spasm.  In  severe  cases  there  will  be  no  movement  dis- 
cernible, the  joint  will  seem  to  be  ankylosed;  but  a  pa- 
tient, careful  examination  will  disclose  the  presence  of  a 
spasm  while  attempts  at  movement  are  being  made ;  and 
spasm  once  felt  rules  out  bony  ankylosis,  regardless  of 
whether  every  other  test,  even  X-rays,  seem  to  point 
toward  bony  ankylosis.  When  a  muscle  passes  over 
two  or  more  joints,  and  one  of  these  joints  is  the  site 
of  a  tuberculous  infection,  it  will  limit  only  the  move- 
ment of  the  diseased  joint  and  will  not  affect  movement 


222         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

in  the  other  joints,  unless  the  movements  in  the  healthy- 
joints  tend  to  convey  some  movement  to  the  diseased 
joint.  Thus  if  the  medio-tarsal  joint  is  the  subject  of 
infection,  the  ankle  joint  may  be  freely  moved  if  none 
of  the  movements  is  extended  to  the  medio-tarsal.  It 
is  the  failure  to  recognize  this  fact  which  sometimes 
leads  to  an  erroneous  diagnosis.  After  examining  the 
sound  foot,  so  as  to  become  familiar  with  the  range  of 
movements  it  enjoys,  each  of  the  three  axes  of  motions 
in  the  suspected  foot  should  be  examined  separately. 
Early  in  the  disease  there  is  not  likely  to  be  absolute 
immobilization  from  the  spasm,  but  only  a  limitation  of 
movement.  Later  this  muscular  spasm  may  cause  com- 
plete fixation. 

Mensuration. —  This  will  disclose  the  atrophy  of  the 
leg,  more  marked  in  disease  of  the  ankle  joint  and  of 
the  subastragaloid  than  of  the  medio-tarsal,  and  also  the 
swelling  of  the  foot.  All  measurements  must  be  made 
at  the  same  distance  from  corresponding  points  on  each 
leg  and  foot.  This  atrophy  is  present  early  in  the  dis- 
ease, increases  as  the  disease  progresses,  and  is  always 
greater  than  would  accompany  disuse  alone. 

X-rays. — ■  The  radiograph  of  a  suspected  foot  will  be 
of  inestimable  value  and  should  always  be  had,  if  possible, 
before  committing  oneself  to  a  positive  diagnosis.  In 
very  early  cases,  however,  if  all  the  clinical  signs  and 
the  history  point  to  a  tuberculous  infection,  even  though 
the  radiograph  is  negative,  I  should  advise  that  the  treat- 
ment be  directed  toward  this  disease.     When  the  symp- 


TUBERCULOUS   AND   GONORRHEAL  DISEASE 


223 


toms  are  pronounced,  the  absence  of  confirmation  by  the 
radiograph  is,  of  course,  of  the  greatest  importance. 

Tuberculin  Test. —  The  various  tests  with  tuberculin 
may  be  used  with  the  same  advantage  obtained  in  its  use 
for  diagnostic  purposes  in  other  suspected  regions.  A 
positive  reaction  may  come  from  the  presence  of  a  focus 
in  some  other  part  of  the  body. 

Differential  Diagnosis. —  The  following  table  for 
differential  diagnosis  is  open  to  criticism  in  many  re- 
spects, but  it  would  manifestly  be  impossible  to  tabulate 
the  many  exceptions  which  may  be  taken  to  the  state- 
ments as  we  have  set  them  forth.  Probably  few  phy- 
sicians of  wide  experience  would  agree  in  all  respects 
with  this  or  any  other  similar  table. 


Flat-foot 

Tubercu- 
lous 
Arthritis 

Gonor- 
rheal 
Arthritis 

Rheuma- 
toid 
Arthritis 

Gout 

PyOGBNIC 

Infection 

Bilateral 

Unilateral 

Unilateral 

Unilateral 

Unilatera 

Unilateral 

Age 

10-30 

2-20 

15-25 

2-40 

35-60 

Any  age 

Sex 

Male 

Either 

Male 

Female 

Male 

Either 

Previous 
attacks 

None 

None 

Likely 

Likely 

Likely 

None 

Onset 

Slow 

Slow 

Slow  or 
rapid 

Slow 

Rapid 

Rapid 

Constitu- 
tional 
symptoms 

Absent 

Absent 

Slight 

Absent 

Slight 

Marked 

Location 

Astragalo- 

scaphoid 

joint 

Infected 
area  " 

Tendon 

sheaths 

Bursae 

Plantar 

fascia 

Involved 
joints 

Great  toe 

Infected 
joints 

224 


DISEASES    AND    DEFORMITIES    OF    THE    FOOT 


Tubercu- 

Gonor- 

Rheuma- 

Flat-foot 

lous 

rheal 

toid 

Gout 

Pyogenic 

Arthritis 

Arthritis 

Arthritis 

Infection 

Position 

Everted 

Everted 

Everted 

About 

Extension 

Varies 

of  foot 

abducted 

abducted 
plantar- 
flexed 

abducted 

normal 

great  toe 

widely 

Swelling 

Inner 
border  of 
foot 

Fusiform 

Diffuse 

May  be 

absent 

Great  toe 

Varies 

Color 

Purplish 

White 

Normal 

Normal 

Purplish 

Red 

Heat 

Absent 

Slight 

Absent 

Absent 

Slight 

Marked 

Tender- 

Slight, 

Over 

Over  me- 

Inflamed 

ness 

Over 

over  m- 

bursae 

Not 

tacarpal- 

area 

Hunter's 

fected 

tendon 

marked 

phalan- 

capsule 

area 

sheaths 
plantar 
fascia 

geal  joint 
of  large 
toe 

Pain 

Only  after 

Slight  but 

After  use 

Continu- 

Worse at 

use 

contmu- 

Ache 

ous 

night 

Continu- 

Soreness 

ous 

Increased 

Constrict- 

ous 

Bruise 

Worse  at 

night 

Sharp 

by  use 
Dull 

ing  char- 
acter 

throbbing 

Muscular 

Peroneus 

Peroneal 

May  be 

Extensor 

spasm 

longus 

muscles 

absent 

of  great 

Marked  in 

and  brevis 

Most 
marked: 
P.  longus 
and  brevis 
or  gastroc- 
nemius 

toe 

any 

movement 
of  involve 
joints 

Blood  test 

Negative 

Tuber- 
culin 
reaction 

Compli- 
ment fixa- 
tion for 
gonococci 

Compli- 
ment fixa- 
tion for 
auto-infec- 
tious mi- 
cro-organ- 
ism from 
teeth  or 
elsewhere 

Negative 

Negative 

Condi- 

None 

Atrophy 

Gonor- 

Results of 

tions  to 

of  leg 

rheal  uri- 

attacks  in 

be  sought 

muscles 

thritis  or 

other 

elsewhere 

ophthal- 
mia 

joints 

Tophi 

None 

Plate   IV. — Tl'berculous   Disease  of  the  Foot 


The  disease  has  extended  so  as  to  involve  the  tibia, 
astragalus,  calcaneum  and  scaphoid.  At  the  time  this 
photograph  was  taken  the  equinus  was  practically 
overcome  but  valgus  and  aversion  are  still  marked. 
The  sinuses  are  discharging  freely  and  spasm  is  evi- 
dent upon  the  least  attempt  at  passive  motion.  An 
ankle-brace,  crutches,  and  helio-therapy,  with  extra- 
urban  hospital  care,  arrested  the  disease,  healed  the 
sinuses  and  reduced  all  deformities. 


TUBERCULOUS   AND   GONORRHEAL  DISEASE  225 

TREATMENT 

Immobilization. —  It  is  impossible  to  obtain  trac- 
tion in  order  to  prevent  inter-articular  pressure;  so  that 
immobilization,  with  the  removal  of  weight-bearing  dur- 
ing the  acute  stage,  is  the  object  to  be  sought.  Immo- 
bilization may  be  obtained  by  using  plaster-of-Paris,  a 
steel  brace,  molded  leather,  porous  plastic  felt,  or  silicate 
bandages.  In  the  hands  of  those  who  are  not  expert 
orthopedic  surgeons,  the  plaster-of-Paris  is  probably  the 
most  satisfactory  to  use,  especially  while  the  disease  is 
active  and  while  deformity  and  swelling  exist.  If  the 
ankle  joint  or  the  subastragaloid  is  involved,  the  knee 
should  be  included  in  the  bandage  so  as  to  insure  con- 
trol over  the  gastrocnemius.  Care  must  be  tLken  to  put 
the  foot  up  in  the  best  position  obtainable  without  using 
too  much  force.  If  some  equinus  and  abduction  are 
present,  they  need  not  be  corrected  at  once,  as  these 
deformities  will  become  less  as  the  foot  improves,  and 
any  violence  to  the  diseased  area  is  to  be  avoided.  If 
sinuses  exist,  fenestra  must  be  cut  in  the  plaster  to 
permit  of  their  being  dressed.  The  plaster  should  be 
changed  about  every  two  weeks  if  deformity  and  swelling 
are  present,  so  as  to  allow  further  correction  of  the  posi- 
tion and  the  better  fitting  of  the  bandage  as  the  swelling 
subsides.  When  deformity  and  swelling  are  absent,  the 
bandage  needs  to  be  changed  but  once  a  month.  While 
the  disease  is  active,  the  foot  should  not  be  allowed  to 
hang  down.     Confinement  in  bed  is  not  necessary  nor 


226         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

advisable,  but  the  foot  should  be  kept  elevated  the  greater 
part  of  the  time. 

With  the  reduction  of  deformity,  disappearance  of 
swelling  and  lessening  of  spasm,  and  when  these  signs  are 
not  greatly  marked  at  the  first  consultation,  ambulatory 
treatment  may  be  tried.  It  is  at  this  stage  that  a  brace 
is  especially  indicated:  if  properly  fitted,  it  is  not  only 
more  comfortable  than  plaster  but  better  admits  a  close 
observation  of  the  progress  being  made.  The  slightest 
increase  of  spasm  is  indication  of  insufficient  protection. 
It  should  not  be  necessary  to  wait  for  the  grosser  signs, 
actual  deformity  or  immobilization  or  swelling,  to  recog- 
nize Nature's  assertion  that  we  are  not  properly  caring 
for  the  condition.  At  the  first  hint,  an  increase  of 
spasm,  a  shorter  range  of  motion,  the  treatment  must 
be  changed. 

Braces. —  There  are  three  braces  which  may  be  used 
in  tuberculous  disease  of  the  foot:  the  ankle  brace,  the 
long  leg  brace  of  Shaffer's,  and  the  Thomas  knee  brace. 

The  ankle  brace  consists  of  a  foot  piece  with  two  side 
bars  extending  to  the  knee  and  has  no  joints.  Instead 
of  a  calf  band  it  has  a  band  connecting  the  tops  of  the 
leg-bars  and  passing  in  front  of  the  tibia,  with  a  strap 
passing  around  the  calf  and  completing  the  circumfer- 
ence of  the  leg.  The  foot-piece  must  be  made  to  fit 
accurately  the  bottom  of  the  foot  so  that  it  will  act  as  a 
perfect,  immobilizing  splint.  It  may  be  made  over  a 
plaster  cast  of  the  foot,  or  made  from  an  outline  of  the 
foot  and  fitted,  altered,  and  refitted  until  perfectly  satis- 


TUBERCULOUS    AND    GONORRHEAL  DISEASE  22/ 

factory.  The  use  of  a  cast  is  recommended  for  the 
inexperienced  surgeon,  especially  if  the  brace  is  to  be 
made  by  a  mechanic  who  is  not  an  expert  in  this  work. 
The  side  bars  are  formed  to  correspond  to  the  outlines 
of  the  leg  and  are  then  welded  to  the  foot-piece.  They 
must  not  be  riveted  to  the  anterior  cross-bar  until  they 
have  been  fitted  to  the  leg  after  the  welding,  as  it  is  im- 
possible to  alter  them  after  completion  of  the  brace 
without  freeing  them  from  this  cross-bar,  because  any 
change  in  their  outline  must  be  felt  in  other  parts  of  the 
apparatus.  The  cross-bar  should  lie  across  the  lower 
part  of  the  tibial  tubercle,  should  be  well  padded,  and 
should  fit  snugly.  The  object  of  having  this  steel  bar 
in  front  is  to  absolutely  prevent  any  dorsal  flexion,  which 
is  not  possible  with  only  a  strap  in  this  location.  A  strap 
to  buckle  over  the  ankle  is  riveted  to  the  bottom  of  the 
foot-piece,  just  behind  the  line  of  the  leg-bars.  This 
strap,  together  with  a  laced  shoe  going  on  over  the  brace, 
will  securely  hold  the  foot  against  the  foot-piece,  and 
render  immobilization  complete.  During  the  stage  of 
convalescence,  if  the  disease  has  been  confined  to  the 
forefoot,  an  ankle  brace  may  be  applied  permitting  move- 
ment at  the  ankle. 

Campbell  Brace. — The  long  leg  brace  which  may  be 
used  for  these  cases  is  called  the  Campbell  brace  by  Dr. 
Shaffer.  The  name  is  derived  from  that  of  the  first 
patient  for  whom  he  devised  it,  just  as  he  named  the 
Condon  brace  after  the  first  patient  to  wear  one.  The 
principle  of  this  brace  is  to  transfer  the  concussion  of 


228         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


Fig.  83.  Campbell  Brace 
The  pelvic  band  and  the  perineal  straps  are  properly  adjusted, 
the  sole  plate  brought  against  the  bottom  of  the  foot  and  the  shoe 
put  on  and  laced  up.  Extension  by  means  of  the  ratchet  in  the 
thigh-bar  is  then  applied.  This  pushes  the  shoe  away  from,  below, 
the  foot.  The  thigh  and  calf  bands  are  then  laced.  All  weight- 
bearing  is  removed  from  the  foot.  The  weight  is  transferred  from 
the  body  through  the  tuberosities  of  the  ischii,  the  perineal  bands, 
the  pelvic  band,  the  long  outside  bar  of  the  brace,  to  the  foot- 
piece.  The  lock  at  the  knee  permits  bending  that  joint  when 
sitting;  desirable  not  only  for  convenience,  but  as  an  important 
factor  in  preserving  the  health  of  the  knee  and  the  leg  and  thus  a 
factor  in  curing  the  foot. 


TUBERCULOUS    AND    GONORRHEAL   DISEASE  229 

each  step  and  the  weight  of  the  body,  if  desirable,  from 
the  foot  to  the  tuberosity  of  the  ischium.  It  consists 
of  a  long  outside  leg-bar,  reaching  from  a  foot-plate  to 
a  pelvic  band  and  having  a  joint  at  the  knee.  A  short 
inside  bar  reaches  from  the  middle  of  the  leg  up  to  the 
inner  side  of  the  thigh  at  a  point  two  and  a  half  inches 
below  the  perineum,  and  is  connected  with  the  outside 
bar  by  a  posterior  calf  and  a  thigh  bar.  In  the  outside 
bar,  about  opposite  the  middle  of  the  thigh,  is  a  ratchet, 
which  permits  of  separation  of  the  pelvic  band  and  the 
foot-piece.  The  apparatus  is  applied  with  the  patient 
lying  on  a  couch :  the  pelvic  band  is  adjusted,  strapped, 
and  the  peroneals  buckled  into  place;  then  by  means  of 
the  ratchet,  the  foot-piece  is  brought  up  against  the  sole 
of  the  foot  and  the  shoe  is  put  on  and  laced  up;  with 
the  leg  straight,  the  ratchet  is  made  to  push  the  sole- 
plate,  and  with  it  the  shoe,  away  from  the  sole  of  the 
foot;  then  the  straps  for  the  thigh  and  leg  are  buckled, 
and  the  patient  allowed  to  get  up.  When  properly  ad- 
justed, there  can  be  very  little  weight  conveyed  through 
the  foot  and  none  of  the  concussion  of  walking  will  be 
felt  at  the  diseased  area. 

The  Thomas  Knee  Brace  also  transfers  the  weight- 
bearing  and  the  concussion  of  walking  to  the  tuberosity 
of  the  ischium.  It  consists  of  an  iron  ring,  made  from 
an  outline  obtained  with  a  lead  tape,  so  as  to  fit  snugly 
around  the  thigh  up  against  the  ischeal  tuberosity  and 
at  about  the  top  of  the  great  trochanter  on  the  outer 
side.     Provision  must  be  made   for  covering  the  ring 


230         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 


Fig.  84.  Thomas  Knee-Brace 
This  simple  and  economical  ambulatory  brace  is  suitable  for  use 
in  disease  of  the  foot.  It  removes  weight-bearing  by  transmitting 
the  weight  from  the  pelvis,  through  the  tuberosity  of  the  ischium^ 
to  the  padded  iron  ring  encircling  the  thigh.  From  this  ring  the 
weight  is  taken  by  the  upright  bars,  to  the  cross-piece  below  the 
foot.  The  length  of  the  uprights  may  be  adjusted  by  the  screws 
in  their  lower  part.  Straps  are  placed  about  the  thigh  and  leg,  and 
a  broad  band  supports  the  back  of  the  knee.  A  high  shoe  is  worn 
on  the  sound  foot. 


TUBERCULOUS    AND    GONORRHEAL   DISEASE  23 1 

with  leather  and  for  padding  it  where  it  comes  against 
the  tuberosity.  Extending  down  from  the  ring  on  each 
side  is  a  steel  rod  having  a  crossbar  connecting  the  lower 
ends.  This  crossbar  should  be  about  an  inch  and  a  half 
below  the  sole  of  the  foot.  The  illustration  shows  how 
a  leather  "  shoe  "  may  be  attached  to  the  crossbar. 

Whether  a  brace,  and  what  kind  of  brace,  or  whether 
plaster-of-Paris  is  to  be  used,  must  depend  upon  the 
exact  site  of  the  diseased  process;  its  extent;  the  pres- 
ence of  deformity;  the  condition  of  the  patient,  his  age, 
weight,  and  general  activity;  and  the  control  over  the 
case  which  the  surgeon  can  be  sure  of  maintaining. 
With  the  Thomas  brace  a  high  shoe  should  be  worn  on 
the  sound  foot  and  sometimes  crutches  should  be  pro- 
vided. With  Shaffer's  brace  crutches  are  frequently 
needed.  With  the  ankle  brace  it  is  frequently  necessary 
to  interdict  all  walking  and  standing  until  convalescence 
is  established.  All  of  these  matters  must  depend  on  the 
ability  of  the  surgeon  to  recognize  the  slightest  changes 
in  the  condition  and  on  his  promptness  in  making  changes 
in  treatment  to  meet  the  indications. 

Bier's  Treatment. — Congestion,  theoretically  carry- 
ing to  the  diseased  area  an  increased  supply  of  blood  with 
its  bactericidal  properties,  should  be  of  great  value  in 
the  treatment  of  these  cases.  While  some  of  the  re- 
ports of  cases  treated  by  this  method  seem  to  be  most 
encouraging,  many  surgeons  have  been  disappointed  in 
its  use.  Perhaps  one  great  source  of  failure  in  using 
congestion,  is  to  be  found  in  the  too  great  dependence 


232         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

which  some  have  placed  on  it.  Its  use  is  sometimes  ac- 
companied by  a  relaxation  of  the  minute  care  which 
should  always  be  given  to  the  general  and  to  the  local 
treatment.  If  the  bactericidal  power  of  the  blood  is 
low,  or  is  allowed  to  deteriorate,  the  increased  supply  of 
such  blood  may  not  be  equal  to  the  normal  supply  of 
blood  which  has  been  carefully  built  up  by  general  treat- 
ment. So  fixation  and  relief  from  functionating  may  be 
more  powerful  in  preventing  an  increase  in  the  local 
infection  than  congestion,  and  I  do  not  believe  they  can 
be  slighted  without  disastrous  results.  Bier's  treatment 
should  be  regarded  as  an  adjunct  to  other  treatment. 

The  object  of  this  treatment  is  to  obtain  hyperemia; 
redness,  heat,  and  swelling.  Stasis  is  to  be  avoided  as 
injurious.  The  bandage  should  be  applied  about  the 
middle  third  of  the  thigh.  It  should  not  cause  any  dis- 
comfort. If  a  rubber  bandage  is  used  it  should  be  ap- 
plied over  a  cotton  or  flannel  bandage,  so  as  to  avoid 
any  effect  of  the  rubber  on  the  skin.  If  an  elastic  band- 
age, not  of  pure  rubber,  is  used,  it  should  not  have  a 
selvage;  it  must  be  equally  elastic  throughout.  Before 
applying  the  bandage,  note  the  condition  of  the  skin; 
its  temperature  and  color,  the  superficial  veins,  the  ap- 
pearance of  any  sinuses,  and  the  pulse  at  the  ankle. 

There  are  two  distinct  methods  of  proceeding.  A 
degree  of  congestion  may  be  obtained  in  which  the  veins 
are  made  more  prominent,  fuller,  but  they  remain  easily 
compressible  by  the  finger,  and  the  skin  becomes  just 
barely  blue-red,  not  cyanotic.     The  bandage  is  worn  for 


TUBERCULOUS    AND    GONORRHEAL   DISEASE  233 

five  or  six  hours  every  day,  the  time  being  reduced  to 
three  hours  after  a  week  or  ten  days  and  after  that  to 
but  one  hour  a  day.  In  the  other  method,  called  the 
"  intensification  congestion  method,"  the  bandage  is  ap- 
plied more  firmly  and  the  skin  becomes  bluish-red. 
There  is  some  swelling  but  no  edema.  A  prickly  sen- 
sation may  be  felt,  but  no  pain,  Cantile  thinks  this  is 
the  better  method  of  treatment  in  experienced  hands. 

Tuberculin  Treatment. —  The  therapeutic  value  of 
injections  of  tuberculin,  in  the  treatment  of  bone  tubercu- 
losis, has  been  very  widely  tested  during  the  past  six 
years.  The  consensus  of  opinion,  among  American 
orthopedic  surgeons  at  least,  seems  to  be  against  its 
having  any  pronounced  value.  I  have  given  it  a  careful 
trial  at  the  New  York  State  Hospital  for  Crippled  and 
Deformed  Children  and  also  in  private  practice,  having 
used  it  in  over  forty  cases,  in  most  of  which  the  opsonic 
index  was  regularly  ascertained,  the  clinical  signs  re- 
corded once  a  week  or  at  least  once  a  fortnight,  and 
notes  kept  of  the  general  condition,  including  weight, 
appetite,  urinalysis,  and  general  appearance.  A  report 
of  over  twenty  of  these  cases  was  published  in  the  Jour- 
nal of  The  American  Orthopedic  Association  in  1909, 
in  conjunction  with  Hastings,  who  undertook  the  labora- 
tory work.  The  opinion  which  I  now  hold  regarding 
tuberculin  in  these  cases  is,  that  in  most  instances  it  is 
a  valuable  tonic;  that  it  is  not  injurious  in  any  way  if 
constant  watch  is  kept  for  the  slightest  reaction  and  any- 
thing more  marked  than  a  slight  malaise  avoided;  that 


234         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

its  influence  on  the  local  lesion  is  dependent  on  any  im- 
provement in  the  general  condition,  appetite,  etc. ;  and 
that  it  in  no  wise  warrants  any  less  careful  attention  to 
details  of  other  treatment.  In  some  cases  it  seemed  to 
shorten  the  time  of  treatment,  but  not  so  markedly  that 
it  could  be  highly  recommended.  It  may  be  that  this 
line  of  treatment  will  yet  be  perfected  so  that  it  may  be 
used  to  greater  advantage. 

It  may  be  administered  during  any  stage  of  the  disease. 
The  initial  dose  should  be  from  .0001  to  .0002  mg.  or 
nx  3  of  a  solution,  i  c.c.  of  which  equals  .000001  gm. 
The  next  dose  may  be  nx  5,  and  so  on  up  until  .001  mg. 
or  "PX  i^  of  a  solution,  i  c.c.  of  which  equals  .00001  gm. 
is   reached. 

Until  the  dose  of  .001  mg.  is  given,  the  inoculations 
should  be  given  every  three  or  four  days,  twice  a  week. 
After  that  every  five  days,  or  once  a  week.  When  the 
dose  has  reached  .01  mg.  or  nx  2  of  a  solution,  i  c.c.  of 
which  equals  .0001  gm.,  the  vaccinations  should  be  made 
once  in  ten  days  and  the  greatest  of  care  should  be  taken 
to  guard  against  reactions.  Larger  doses  are  not  ad- 
visable. The  treatment  should  be  interrupted  for  a 
month  or  two  and  the  second  series  of  inoculations 
should  be  begun  with  from  .0001  to  .0002  mg. 

A  slight  local  reaction,  whether  simply  an  erythematous 
condition  of  the  skin  or  an  indurated  mass  at  the  site  of 
injections  is  of  no  consequence,  but  injection  should  be 
made  elsewhere  until  the  part  is  again  normal. 

The  temperature  should  be  taken  every  four  hours, 


TUBERCULOUS    AND    GONORRHEAL   DLSEASE  235 

for  forty-eight  hours  before  and  after  each  inoculation. 
A  sudden  or  unusual  rise  in  temperature  had  better  be 
followed  by  a  much  reduced  dosage  or  an  omitted  do- 
sage. 

Constitutional  symptoms,  such  as  nausea,  chilly  sen- 
sations and  headache,  occurring  within  forty-eight  hours 
of  a  vaccination  demand  a  cutting  of  the  dosage  by  one- 
half,  and  a  slower  rate  of  progression. 

The  opsonic  index  is  not  to  be  used  as  a  guide  to  the 
removal  of  mechanical  apparatus. 

Tuberculous  individuals  show  variations  in  the  indices 
which  are  more  marked  than  in  the  normal  individual. 
Inoculations  are  to  be  continued  regardless  of  the  indices ; 
the  clinical  symptoms  alone  to  be  the  guide.  Tuberculin 
can  be  safely  given  without  ascertaining  a  single  opsonic 
index. 

Heliotherapy. —  The  sun's  rays  may  be  used  with 
decided  advantage  if  the  treatment  is  carried  out  in  a  con- 
scientious manner.  The  indifferent  exposure  of  a  tu- 
berculous foot  to  the  sunlight  cannot  be  of  value. 
Probably  the  therapeutic  value  derived  from  the  sun 
comes  from  a  stimulation  of  metabolism  and  the  diseased 
area  is  benefited  more  through  a  constitutional  effect 
than  through  any  direct  local  effect.  Rollier's  method 
is  to  begin  with  a  short  exposure  of  one  part  and  then 
to  increase  at  each  treatment  the  time  of  exposure  of  that 
part  and  add  a  new  area  for  a  short  original  exposure. 
Thus  at  the  third  treatment  the  left  leg  may  be  exposed 
thirty  minutes,  the  left  thigh  twenty  minutes  and  the 


236         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

right  leg  ten  minutes.  This  is  continued  until  the  entire 
body  is  exposed  for  one  or  two  hours  a  day,  or  some- 
times longer.  It  would  not  be  possible  to  follow  out 
any  set  of  rules  in  all  cases  nor  in  all  localities.  The 
object  to  be  sought  is  a  tanning  of  the  skin.  Rollier  be- 
lieves that  he  can  prognose  with  some  certainty  the  value 
the  treatment  will  have  in  any  individual  case  by  the 
appearance  of  this  tanning.  Not  only  will  some  skins 
tan  easier  than  others  and  be  less  likely  to  be  burned, 
but  the  condition  of  the  atmosphere,  effecting  the  pene- 
tration of  the  rays,  the  altitude  of  the  sun,  effecting  the 
thickness  of  the  layer  of  the  atmosphere  through  which 
the  rays  must  travel,  and  the  surrounding  conditions 
which  effect  the  reflection  of  the  rays  must  be  factors  of 
importance  in  determining  the  manner  of  prescribing. 
The  head  should  be  protected  by  a  shade-hat  or  a  para- 
sol. In  dry  climates  the  entire  body  may  be  exposed  in 
low  temperatures.  The  protection  of  the  foot  by  a  per- 
fectly fitting  brace  must  not  be  interrupted  during  this 
treatment. 

Sea-bathing. —  If  one  is  treating  a  tuberculous  foot 
at  the  sea  shore,  sea-bathing  is  generally  to  be  recom- 
mended. Not  only  is  it  a  wholesome  stimulation  to 
metabolism  but  I  believe  the  exposure  of  a  sinus  to  the 
sea  water  is  in  itself  beneficial.  The  foot  should  be  well 
protected  by  a  brace  which  may  be  dried  and  reapplied 
after  the  bath  or  a  brace  may  be  used  especially  for  bath- 
ing. Sinuses  may  be  protected  by  one  or  two  layers  of 
gauze. 


TUBERCULOUS    AND    GONORRHEAL  DISEASE  237 

Constitutional  Treatment. —  In  tuberculous  disease 
of  the  bones  of  the  foot,  as  in  that  disease  of  any  of  the 
bones  and  joints,  the  general  condition  of  the  patient  is 
as  essential  as  it  is  in  tuberculosis  of  the  lungs.  The 
best  of  air  and  of  food  is  essential  for  the  preparation 
of  the  opsonins  and  other  body-forces  for  the  conquer- 
ing of  the  disease.  The  best  air  is  always  out-of-door 
air,  preferably  country  air,  and  each  inspiration  is  of 
benefit.  Therefore  an  out-of-door  life,  night  as  well 
as  day,  is  desirable.  This  is  the  treatment  followed  at 
the  New  York  State  Hospital  for  Crippled  and  De- 
formed Children  for  all  of  these  cases.  Regardless  of 
weather  conditions  the  children  are  out  of  doors  night 
and  day,  protection,  of  course,  being  provided  against 
severe  winds,  rain,  and  snow.  Naturally,  sufficient  and 
proper  clothing  must  be  used  to  preserve  the  temperature 
of  all  parts  of  the  body.  Since  this  night  and  day  fresh 
air  treatment  was  adopted  four  years  ago,  there  has  been 
an  undoubted  improvement  in  the  treatment  of  these 
cases  of  bone  tuberculosis. 

Opinion  seems  to  be  divided  as  to  the  advantages  of 
sea  air  over  mountain  air,  some  claiming  superiority  of 
one  and  some  of  the  other.  I  do  not  believe  there  has 
been  a  sufficient  amount  of  data  collected,  or  sufficiently 
careful  analysis  made  of  the  air  in  different  localities, 
for  the  drawing  up  of  positive  statements.  From  my 
personal  observations  I  am  inclined  to  believe  that  with 
the  same  surgical  treatment  many  cases  do  equally  well 
in  either  environment,  others  do  well  at  the  sea  shore 


238         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

but  would  do  better  at  an  altitude  or  vice  versa,  and  yet 
others  progress  very  poorly  at  one  place  who  would  be 
benefited  at  the  other  place.  In  other  words,  for  many, 
perhaps  most,  of  these  cases,  there  is  a  choice  between 
sea  air  and  mountain  air,  but  at  present  there  is  no 
method  of  determining  that  choice  except  by  trial. 

Theoretically  a  meat  diet  might  seem  to  be  advisable, 
the  carnivorous  animals  being  less  subject  to  tuberculous 
infection  than  the  herbivorous;  but  experiments  I  have 
carried  out  have  failed  to  prove  anything  positive  and  a 
mixed  diet  of  nourishing  food  is  all  I  can  recommend. 

Operations. —  In  children  this  is  so  seldom  indicated 
that  it  may  be  stated,  as  a  rule,  Do  not  operate.  In 
adults  new  factors  enter  into  the  question,  such  as  the 
probable  duration  of  treatment  and  the  final  result  of 
prolonged  treatment  as  compared  with  operation.  The 
length  of  time  consumed  by  conservative  treatment  is 
never  under  eighteen  months,  seldom  under  two  years, 
and  more  frequently  three  or  more  years.  The  amount 
of  incapacity  for  work  during  treatment  is  not  only  fre- 
quently of  grave  importance  in  adults ;  but  complete  idle- 
ness, of  such  long  duration,  is  more  or  less  demoralizing 
to  most  characters. 

The  result  of  conservative  treatment  in  the  adult,  must 
be  dependent  to  a  great  extent,  on  the  ability  of  the 
patient  to  follow  the  orders  of  the  surgeon.  If  it  is 
evident  that  the  patient  will  not  be  able  to  follow  the 
necessary  instructions,  including  both  local  and  general 
treatment,  in  their  minutest  details,  then  I  believe  it  to 


TUBERCULOUS   AND    GONORRHEAL  DISEASE  239 

be  wrong  to  enter  upon  them.  The  patient  is  too  often 
allowed  to  "  try "  conservative  treatment,  when  if  he 
was  given  distinctly  to  understand  that  it  would  probably 
be  years  before  he  could  discard  all  protection  to  the 
foot ;  and  that  during  these  years  it  would  be  in  a  greater 
or  less  vulnerable  condition,  likely  to  become  worse 
through  some  minor  accident;  and  that  most  of  the  time 
he  would  have  to  pay  special  attention  to  his  general 
health,  he  would  probably  elect  to  have  some  operative 
interference,  even  an  amputation,  were  it  offered  him. 
In  the  early  stages,  when  the  pain  may  not  be  excessive, 
it  is  easy  to  persuade  the  patient  that  plaster-of-Paris 
will  probably  cure  the  condition,  but  must  be  worn  for 
a  "  long  time."  Several  months  is  a  "  long  time  " ;  but 
if  he  must  submit,  he  will.  Tell  him  it  will  take  three 
or  four  years,  with  the  plaster  or  a  brace,  and  offer  him 
the  alternative  of  an  operation;  and,  I  believe,  most  busy 
men,  who  have  not  much  money  and  have  some  one  or 
more  persons  dependent  upon  them,  would  not  delay 
long  in  selecting  the  radical  treatment.  The  mistake 
lies  in  undertaking  to  give  a  patient  a  "  try  "  at  conserva- 
tive treatment,  when  we  know  that  he  can  not  continue 
it  in  all  its  details  for  more  than  a  year.  When  the 
patient  has  an  abundance  of  means,  will  not  be  made 
"  sick  with  worry,"  and  is  one  to  whom  time  is  little 
object,  the  conditions  are  entirely  different. 

With  a  single  focus,  and  that  limited  to  one  bone, 
excision  is  indicated.  Anything  less,  such  as  opening 
and   curetting  is   inadvisable.     If  the   disease   is   more 


240         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

extensive,  then  every  bone  which  is  surely  infected  should 
be  excised.  And  with  this  excision,  all  possible  infected 
soft  tissue  should  be  cut  away.  The  incisions  should  be 
made  through  healthy  tissue.  It  is  of  less  importance 
to  follow  the  procedure  of  any  classical  operation  for  the 
excision  of  this  or  that  bone  or  part  of  the  foot,  than  it 
is  to  accomplish  that  for  which  the  operation  is  per- 
formed, the  eradication  of  all  diseased  tissue.  The  more 
thorough  the  operation,  the  less  the  danger  of  compli- 
cations, such  as  meningitis,  and  the  shorter  will  be  the 
convalescence.  During  the  early  stage,  operation  need 
produce  but  little  mutilization  of  the  foot,  while  during 
the  latter  stages  amputation  may  be  necessary. 

Sinuses. —  Abscesses  and  sinuses  are  to  be  treated 
according  to  the  symptoms  they  excite  and  the  line  of 
treatment  being  followed.  Where  conservative  treat- 
ment is  being  followed,  the  appearance  of  an  abscess, 
some  time  after  the  patient  has  been  under  observation, 
usually  points  to  some  fault  in  treatment.  The  foot  is 
not  receiving  sufficient  protection  or  the  general  health 
is  not  improving.  Under  efficient  treatment  most  of 
these  abscesses  will  become  absorbed.  It  is  seldom  that 
they  need  to  be  opened  or  aspirated  on  account  of  their 
being  the  source  of  pain.  Sinuses  should  be  kept  scrupu- 
lously clean  so  as  to  prevent  a  mixed  infection.  It  is 
the  mixed  infection  of  sinuses  from  bone  tuberculosis 
which  is  the  greatest  cause  of  amaloid  changes  in  the 
internal  organs.  When  the  sinus  becomes  nearly  dry 
bismuth  paste  may  be  tried  to  hasten  its  closing.     I  give 


TUBERCULOUS    AND    GONORRHEAL   DISEASE  24I 

Beck's  formula  for  its  composition,  but  would  not  recom- 
mend it  to  be  used  unless  a  very  small  quantity  will  fill 
the  sinus  and  that  should  be  injected  without  much 
pressure. 

At  the  beginning,  until  all  discharge  of  pus  has  ceased, 
the  formula  used   is : 

Bismuth  subnitrate  (arsenic  free)   30.0  gms. 

Vaseline  60.0 

Mix  while  boiling. 

Afterward,  the  formula  used    is: 

Bismuth  subnitrate    30.0  grns. 

White  wax 5.0 

Soft  paraffin 5.0 

Vaseline  60.0 

Mix  while  boiling. 

"  Care  must  be  taken  that  no  water  should  accidentally 
be  spilled  into  the  paste  during  the  process  of  boiling, 
and  the  glass  syringes  must  likewise  be  sterilized  by  the 
dry  process  and  the  plunger  dipped  in  sterile  vaseline 
instead  of  water,  before  charging  the  syringe."  The 
fistula  tract  must  be  dried  out,  if  possible,  by  packing 
with  dry  gauze  before  the  injection. 

If  a  case  to  be  operated  has  sinuses  they  should  be 
cut  out,  the  cutting  being  done  through  healthy  tissue, 
so  as  to  include  their  entire  wall.  Abscesses  must  be 
emptied  and  their  walls  cut  entirely  out  with  scissors. 


242  DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

and  then  the  surfaces  left  free  swabbed  with  pure  car- 
bolic followed  by  swabbing  with  alcohol. 

Injections. —  Injections  of  iodoform  and  glycerine, 
ten  per  cent.,  are  frequently  used  in  treating  tubercu- 
lous disease  of  joints,  especially  after  abscess  formation. 
Instead  of  glycerine,  ether,  olive  oil,  and  other  vehicles 
are  also  used.  Glycerine  may  be  rendered  sterile  by 
adding  one  per  cent,  of  carbolic  acid ;  and  the  iodoform, 
by  being  steeped  in  a  carbolic  solution,  one  in  twenty. 
The  skin  may  be  prepared  with  tincture  of  iodine  and 
then  frozen  with  ethel  chloride.  The  needle  is  intro- 
duced in  such  a  way  as  to  avoid  important  structures  or 
areas  which  appear  to  be  breaking  down.  Any  pus  is 
first  aspirated.  The  syringe,  holding  two  or  three 
ounces  is  then  screwed  on  the  trochar,  and  the  injection 
made  slowly  and  with  considerable  pressure.  Upon 
withdrawal  of  the  trochar,  a  pledget  of  cotton  dipped  in 
a  fifty  per  cent,  solution  of  alcohol  is  pressed  against 
the  puncture  for  several  minutes.  Then  a  pad  is  ap- 
plied and  firmly  bound  on  with  a  bandage.  Considerable 
pain  may  result,  lasting  in  some  instances  for  several 
days;  but  this  will  vary  greatly  in  individual  cases.  If 
it  seems  to  be  advisable,  the  injection  may  be  repeated 
in  about  four  weeks.  A  combination  of  iodoform  and 
glycerine  is  also  used  in  the  treatment  of  sinuses.  It 
should  be  injected  through  an  olive  pointed  tube,  and 
the  injections  repeated  at  about  every  dressing. 

Kirmisson  prefers  a  one  in  ten  solution  of  iodoform 
in  ether.     He  injects  only  that  amount  which  he  feels 


TUBERCULOUS   AND   GONORRHEAL  DISEASE  243 

can  be  safely  left  in  the  cavity;  five  to  twenty  grams. 
The  trochar  he  uses  has  a  cock  which  he  closes  at  the 
completion  of  the  injection  and  which  thus  allows  the 
confined  ether  to  coat  thoroughly  with  the  iodoform  all 
the  tissues  with  which  it  comes  into  contact  as  it  expands. 
After  a  few  moments,  he  opens  the  cock  and  the  ether 
escapes,  thus  removing  all  pain  from  pressure. 

Camphorated-thymol  as  an  injection  is  recommended 
by  some,  on  account  of  its  liquefying  action,  if  the  con- 
tents of  the  abscess  are  caseous  (Calve  and  Gauvain, 
quoted  by  Tubby).  It  is  prepared  by  mixing  two  parts 
of  camphor  to  one  of  thymol,  the  formula  determined 
by  Menard. 

GONORRHEAL   INFECTION    OF   THE    FOOT 

Next  to  the  knee,  the  foot  is  the  most  frequently  in- 
volved in  this  form  of  arthritis.  Most  writers  agree 
that  men  are  more  often  attacked  than  women.  "  Women 
possess  a  strange  immunity"  (Keys).  But  of  fifty-six 
cases  observed  by  C.  F.  Marshall,  quoted  by  Tubby, 
eighteen  were  men  and  thirty-eight  women. 

It  usually  appears  after  the  first  week  of  the  infection 
and  may  come  on  any  time  during  the  later  stages. 
There  are  several  forms  in  which  the  disease  presents 
itself :  it  may  include  several  joints  and  be  ushered  in 
with  symptoms  resembling  those  attending  an  attack  of 
acute  articular  rheumatism  or  it  may  be  confined  to  one 
foot  and  cause  but  slight  constitutional  disturbance.  The 
differential  diagnosis  of  the  former  rests  on  the  arthritis 


244         DISEASES    AND   DEFORMITIES    OF    THE   FOOT 

remaining  in  the  joints  primarily  infected  and,  if  a  new- 
joint  is  attacked,  in  its  not  immediately  subsiding  in 
those  first  attacked;  on  the  disproportion  between  the 
local  and  the  general  condition,  the  temperature,  pulse, 
and  sweating  being  less  severe  in  the  gonorrheal  arthritis 
and  more  quickly  subsiding;  on  the  absence  of  effect 
from  the  use  of  salicylates ;  on  the  presence  of  a  uri- 
thritis,  and  on  the  finding  of  gonococci  in  the  flakes 
aspirated  from  the  joint. 

If  but  one  joint  is  involved,  and  the  constitutional 
symptoms  are  not  pronounced,  it  may  easily  be  mistaken 
for  a  tuberculous  infection.  The  rapidity  of  the  onset 
should  put  one  on  his  guard,  although  it  must  be  remem- 
bered that  a  gonorrheal  arthritis  may  be  a  chronic  con- 
dition. Persistent  search  should  be  made  in  every 
doubtful  case  for  a  possible  origin  of  a  gonorrheal 
infection. 

The  brunt  of  the  attack  may  be  on  the  synovial  mem- 
brane, causing  an  exudation  of  fibrin,  which,  if  not 
interfered  with,  may  form  bands  of  adhesions  interfering 
with  joint-movement  and  finally  eroding  the  cartilage 
and  causing  complete  ankylosis;  or  the  periarticular 
structures  may  be  the  most  involved,  causing  pronounced 
swelling,  with  marked  tenosynovitis,  and  heat  and  red- 
ness. Signs  of  inflammation  are,  however,  frequently 
absent  even  when  the  swelling  is  pronounced  and  abscess 
formation  does  not  take  place  unless  a  mixed  infection 
is  present.  The  plantar  fascia  and  the  bursae  between 
the  tendo  Achillis  and  the  os  calcis  and  underneath  the 


TUBERCULOUS    AND    GONORRHEAL   DISEASE  245 

posterior  tubercle  of  the  os  calcis,  are  frequently  involved. 
The  pain  may  be  as  severe  as  that  accompanying  articu- 
lar rheumatism,  but  rest  and  immobilization  are  much 
more  effective  in  allaying  it. 

A  number  of  cases  of  gonorrheal  arthritis  have  been 
reported  in  infants,  complicating  the  same  infection 
elsew^here. 

The  prognosis  must  depend  to  a  great  extent  on  the 
tissues  involved,  on  the  virulence  of  the  invading  organ- 
ism, and  on  w^hether  or  not  there  is  a  mixture  of  other 
bacteria.  In  the  mildest  cases,  six  weeks  or  two  months 
may  produce  a  cure;  while  in  the  severer  forms,  six 
months  may  be  necessary,  and  a  perfect  restoration  may 
not  then  have  been  made. 

Treatment. —  To  relieve  the  pain  the  foot  should  be 
put  at  rest  in  the  most  comfortable  position.  A  posterior 
splint  made  of  plaster-of-Paris,  reaching  from  the  toes 
to  the  middle  of  the  thigh,  is  very  satisfactory.  The 
foot  should  be  dressed  in  a  thick  layer  of  cotton-wool 
before  the  splint  is  applied.  It  may  be  well  during  the 
first  few  days  to  keep  the  patient  in  bed  with  the  foot 
elevated.  These  are  considered  ideal  cases  for  the  ap- 
plication of  Bier's  treatment  and  those  who  have  had 
the  greatest  experience  with  it,  are  enthusiastic  in  its 
power  to  relieve  the  pain  and  to  hasten  a  cure.  No  in- 
ternal medicine  is  indicated  other  than  general  tonics, 
if  deemed  necessary,  or  possibly  alkalies  for  the  urine. 

The  font  of  the  infection  should  be  attacked  immedi- 
ately.    If   the   surgeon   is   not   greatly   experienced   in 


246         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

genito-urinary  work  he  had  much  better  call  in  one  who 
is,  if  such  a  one  is  available,  rather  than  attempt  to  treat 
this  factor  himself. 

Aspiration  through  a  large-bore  needle,  or  a  small 
incision,  a  puncture,  had  better  be  performed  early  if 
there  is  much  deposit  in  the  joint.  This  relieves  pain, 
hastens  resolution,  and  renders  material  available  for  a 
bacteriological  examination.  The  joint  may  be  washed 
out  with  a  sterile  salt  solution,  a  carbolic  solution,  i  in 
40,  or  a  bichloride  solution  i  in  5000.  In  a  mixed  in- 
fection this  is  absolutely  necessary.  If  the  ankle  and 
foot  are  boggy  and  tense  and  much  tenosynovitis  exists, 
several  long  incisions  may  be  made  and  the  foot  placed 
in  an  antiseptic  bath  or  put  up  in  a  wet  dressing  which 
should  be  kept  wet.  Usually,  however,  in  this  disease 
of  the  foot,  immobilization  and  Bier's  band  will  be  all 
the  local  treatment  necessary. 

The  danger  of  a  resulting  ankylosis  and  of  flat-foot 
is  always  very  imminent,  and  therefore  immobilization 
must  be  interrupted  by  passive  movements  after  the  first 
few  days.  When  the  acuteness  has  subsided,  the  espe- 
cially painful  spots  remaining,  the  bursae  and  the  tenosyn- 
ovitis, may  be  greatly  relieved  by  the  Paquelin  cautery. 
Bier's  treatment,  hot  air  baths,  and  douching  with  hot 
and  cold  water  will  often  render  supple,  joints  which 
seemed  to  be  permanently  limited  in  motion. 

Vaccine  treatment  should  be  reserved  for  the  later 
stages.  Stock  vaccine,  which  is  put  up  by  the  large 
pharmaceutical  houses,  is  quite  efficient.     In  case  of  a 


TUBERCULOUS    AND    GONORRHEAL   DISEASE  247 

mixed  infection,  however,  it  is  much  better  to  use  an 
autogenous  vaccine. 

A  brace  which  permits  movements  within  the  range 
of  comfort  is  advisable,  as  it  permits  of  ambulatory- 
treatment,  protects  the  foot  from  deformity,  flat-foot, 
and  preserves  the  movements  which  are  not  already 
limited. 


CHAPTER  X 
OTHER  AILMENTS 

PAINFUL    HEEL  METATARSALGIA  MORTON's    TOE  

HALLUX  VALGUS HAMMER  TOE RAYNAUD'S  DIS- 
EASE   INTERMITTENT      LIMPING CHILBLAINS 

FROST        BITE HYPERIDROSIS CORNS INGROW- 
ING  TOE   NAIL. 

PAINFUL  HEEL 

This  is  a  condition  in  which  the  greatest  pain,  per- 
haps the  only  pain,  is  described  as  being  in  the  bottom  of 
the  heel.  It  is  most  frequently  found  in  people  who 
have  to  be  on  their  feet  a  great  deal,  as  policemen,  and 
has  in  consequence  been  called  "  policeman's  heel."  It 
is  aggravated  by  use  of  the  foot  and  may  be  entirely 
absent  during  rest,  but  the  painful  spot  can  always  be 
found  by  digital  pressure. 

Examination. —  In  appearance  the  foot  may  be 
nearly,  if  not  quite  normal.  Upon  the  patient's  stand- 
ing there  may  be  slight  evidence  of  weakness,  some 
bulging  along  the  inner  border,  and  some  deflection  out- 
ward of  the  tendo  Achillis;  but  usually  any  apparent 
abnormality  is  not  sufficient  to  account  for  the  symptoms. 
The  dome  may  appear  normal  and,  sometimes,  even 
somewhat  exaggerated. 


OTHER    AILMENTS  249 

Palpation. —  Abduction  and  adduction  may  be  nor- 
mal and  also  inversion  and  eversion.  It  is  necessary  to 
say  "  may  be  "  as  painful  heel  may  exist  with  oncoming 
flat-foot.  Dorsal  flexion  will  almost  always  be  limited 
to  a  right  angle;  and,  in  my  opinion,  this  is  the  primary 
cause  of  the  condition. 

Etiology. —  According  to  my  theory,  the  painful 
spot  or  spots  (there  may  be  two)  are  caused  by  a  trau- 
matic periostitis  set  up  by  the  pulling  and  tearing  of  the 
periosteum  by  the  plantar  tissues.  From  his  experience, 
Konig  is  convinced  that  "  calcaneum  spur  "  in  itself  does 
not  cause  pain;  the  pain  develops  when  the  spur  is  injured 
by  some  trauma  or  becomes  involved  in  an  infectious 
process  originating  in  an  adjoining  bursa  and  frequently 
of  gonorrheal  origin.  The  strain  of  a  shortened  heel- 
cord,  especially  one  not  limiting  dorsal  flexion  to  more 
than  a  right  angle,  is  felt  mostly  in  these  plantar  tissues, 
as  explained  under  non-deforming  club-foot.  Whereas 
this  strain  may  result  in  a  giving- way  or  stretching  of 
these  tissues,  in  these  cases  under  discussion  the  greatest 
effect  is  in  the  traumatism  to  the  periosteum  at  the  at- 
tachment of  the  plantar  fascia  and  other  plantar  tissues 
to  the  tubercles  of  the  os  calcis,  and  in  a  resulting  chronic 
inflammation,  a  chronic  periostitis.  A  further  result,  if 
it  continues,  is  an  excess  of  bony  growth  which  may 
be  clearly  apparent  in  the  radiograph. 

Pathology. —  The  examination  of  these  exostoses, 
when  they  have  been  removed  by  operation,  has  shown 
a  large  number  to  be  infected  with  gonococci,  and  quite 


250         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

reasonably,  these  exostoses,  and  therefore  painful  heel, 
have  been  considered  by  many  surgeons  as  a  complica- 
tion of  gonorrhea.  My  only  quarrel  with  this  classi- 
fication is  that  it  seems  to  be  probable  that  the  cocci 
have  made  a  nidus  at  these  spots  only  after  the  chronic 
periostitis  has  been  set  up  by  the  strain  due  to  the  short- 
ened heel-cord.  Whether  or  not  there  is  a  simple 
traumatic,  or  a  gonorrheal  infectious  periostitis,  the 
history,  and  especially  a  complement-fixation  test,  will 
help  in  deciding. 

Treatment. —  The  condition  of  a  shortened  heel- 
cord  should  be  relieved  and  if  a  weak- foot  exists  it  should 
receive  appropriate  treatment.  The  acute  symptoms 
may  sometimes  be  ameliorated  by  providing  a  lift  to  the 
heel  which  is  so  formed  as  to  relieve  the  painful  spots 
from  direct  pressure.  As  such  a  lift  will  also,  by  rais- 
ing the  heel,  relieve  some  of  the  strain  on  the  plantar 
tissues,  as  the  range  of  flexion  of  the  tibia  on  the  plane 
of  the  ground  in  walking  is  thereby  increased,  further 
relief  may  be  obtained. 

Operation. —  In  the  hands  of  some  surgeons,  ex- 
cision of  the  exostoses  gives  splendid  results.  They 
shpuld  be  reached  from  a  lateral,  longitudinal  incision 
on  the  external  aspect,  so  as  to  avoid  a  scar  in  the  tread 
of  the  heel.  Doubtless  the  rest  in  the  plaster-of-Paris 
dressing  after  the  operation  is  of  material  benefit,  too. 

Vaccine  treatment  in  cases  where  a  complement-fixa- 
tion test  has  been  positive  may  be  tried. 


OTHER   AILMENTS 


251 


METATARSALGIA 

Metatarsalgia  is  a  painful  condition  in  which  the  part 
of  the  dome  formed  by  the  metatarsal  bones,  the  trans- 
verse arch,  is  weakened,  lowered,  and  sometimes  obliter- 
ated. Normally  this  part  of  the  foot  is  very  flexible, 
although  any  one  direction  of  movement  is  greatly  lim- 
ited.    This  flexibility  is  essential  to  proper  poise  and 

( 


Figs.  85-86.    Transverse  Section  of  the  Forefoot 

Fig.  85  shows  the  normal  position  of  the  metatarsals  and  Fig.  86 

their  abnormal  position  when  their  arch  is  flattened. 

balance.  If  for  any  reason  the  muscles  controlling  the 
metatarsals  become  weak,  the  ligaments  will  stretch,  the 
arch  be  lowered,  and  movement  between  these  bones 
be  lost,  together  with  the  finer  movements  of  the  toes. 

Etiology. —  Although  severe  traumatism  may  de- 
stroy this  arch,  as  from  falls  from  a  height  or  by  the 
falling  of  heavy  weights  upon  this  part  of  the  foot,  the 


252         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

condition  under  consideration  is  the  result  of  weakness. 
Usually  it  is  the  effect  of  non-use.  Many  shoes  are 
made  so  as  effectually  to  immobilize  the  forefoot. 

Metatarsalgia  is  more  common  among  women  than 
men.     It  is  rare  during  childhood. 

Pain. —  The  pain  is  of  an  aching  character,  brought 
on  by  use  of  the  foot  and  sometimes  remaining  indefi- 
nitely during  rest.  When  great  weakness  exists,  the 
pain  will  be  excited  whether  the  patient  walks  in  a 
broad-toe  shoe  or  even  bare- footed.  The  pain  is  usu- 
ally confined  to  the  forefoot. 

Examination. —  If  the  condition  is  of  long  standing, 
calluses  will  be  found  under  each  of  the  metatarsal 
heads,  as  a  rule;  although  they  may  be  only  under  the 
second,  third,  and  fourth.  In  the  former  case,  a  right 
angled  contraction  of  the  heel-cord  will  be  present.  The 
forefoot  is  broader  than  normal  and  usually  appears 
thinner,  depressions  sometimes  being  present  between  the 
metatarsals,  as  it  is  seen  between  the  metacarpals  in 
muscular  atrophy  of  the  hand.  On  the  other  hand,  the 
forefoot  may  be  swollen  and  somewhat  inflamed  and, 
according  to  Tubby,  lead  to  a  diagnosis  of  gout  or 
rheumatism.  In  examining  the  shoes,  it  may  be  found, 
as  pointed  out  by  Goldthwait,  that  the  sole  is  concave 
from  side  to  side  so  that  the  first  and  fifth  metatarsals 
are  held  on  a  higher  plane  than  the  others,  and  may  also 
be  concave  antero-posteriorly  so  that  the  phalanges  are 
held  extended  in  a  position  to  force  down  the  heads 
of  the  metatarsals.     The  shape  of  the  sides  of  the  shoes 


OTHER    AILMENTS  253 

will  have  a  very  great  determining  influence  on  the 
position  which  the  bones  will  take  when  the  arch  is 
materially  weakened. 

Treatment. —  This  is  sometimes  so  easy  and  so 
successful  that  one  case  will  bring  renown  to  the  surgeon 
among  the  patient's  friends.  In  others  the  greatest 
'  patience  is  demanded  and  many  therapeutic  measures  will 
be  tried  before  a  cure  is  obtained.  The  object  is  to 
strengthen  the  arch,  and  to  keep  it  in  the  position  of 
strength  while  this  is  being  accomplished.  When  a 
shortened  gastrocnemius  or  a  weak- foot  exists,  appro- 
priate measures  must  be  taken  for  their  treatment.  Ex- 
ercises which  will  strengthen  the  small  muscles  of  the 
forefoot  are  indicated:  picking  up  objects,  as  a  marble 
(Osgood)  ;  and  voluntary  attempts  at  abducting,  flex- 
ing, and  extending  the  toes.  It  is  best  to  be  very  spe- 
cific in  prescribing  the  time  for  these  exercises,  as  five 
minutes  every  morning  and  evening,  with  instructions 
to  move  the  toes,  while  the  shoes  are  on,  at  the  stroke 
of  each  hour  throughout  the  day. 

Support  may  be  had  in  a  number  of  ways :  if  a  brace 
is  to  be  made  for  the  antero-posterior  arch,  it  can  be 
extended  forward  and  a  convexity  made  on  its  upper 
surface  beneath  the  anterior  arch.  If  the  bases  of  the 
metatarsal  bones  are  grasped  in  the  hand  and  slightly 
compressed,  their  heads  slightly  separate  and  they  may 
be  easily  made  to  assume  the  arched  position :  a  piece  of 
adhesive  strapping  about  this  part,  acting  as  does  the 
hand,   may   frequently  be   sufficient   support.     A   piece 


254         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

of  felt,  varying  in  size  according  to  necessity,  may  be 
placed  under  this  arch  and  retained  by  adhesive  plaster. 
A  leather  insole,  exactly  fitting  in  the  shoe  so  that  it 
can  not  vary  its  position,  may  have  secured  to  it  a  piece 
of  felt  or  soft  rubber,  which  will  support  this  arch  when 
the  foot  is  weight-bearing.  When  the  exact  location  for 
this  pad,  on  the  insole,  has  been  determined,  a  cot  may 
be  secured,  opened  at  one  end;  and  this  will  admit  of 
fresh  padding  being  inserted  as  may  become  necessary. 
The  amount  of  padding  which  can  be  tolerated  and  which 
will  afford  relief,  varies  to  a  remarkable  extent.  I  have 
had  patients  made  quite  comfortable,  and  able  to  travel 
abroad,  visiting  art  galleries  and  being  on  their  feet 
a  great  deal,  with  a  piece  of  soft  rubber  the  size  of 
their  own  forefinger  supporting  this  arch ;  while  in  other 
cases  of  apparently  the  same  degree  of  weakness  and 
deformity,  a  piece  of  soft  felt  the  size  of  a  small  pencil, 
could  not  be  tolerated.  Sometimes,  by  having  the  shank 
of  the  sole  of  the  shoe  made  very  narrow,  the  lacing 
over  the  waist  can  be  drawn  so  snugly  as  to  effect  what 
strapping  accomplishes. 

MORTON^S    TOE 

Morton,  of  Philadelphia,  was  the  first  one  to  describe 
this  condition.  It  is  often  confused  with  anterior  meta- 
tarsalgia,  but  has  a  distinct  pathology.  The  two  con- 
ditions may  be  present  at  the  same  time. 

Etiology. —  Morton's  toe  is  a  neuritis,  caused  by 
nerve  pressure  by  the  head  of  the   fourth  metatarsal. 


OTHER    AILMENTS  255 

It  may  be  pressure  on  one  of  the  larger  branches  of 
the  external  plantar  nerve  or  on  the  nerve  formed  by 
communicating  branches  of  the  external  and  internal, 
or  on  some  one  of  the  filaments  from  the  plantar,  or 
from  the  anterior  tibial.  The  pressure  is  usually  between 
the  head  of  the  fourth  metatarsal  and  the  base  of  the 
first  phalanx  of  the  fifth  toe,  or  it  is  an  intermetatarsal 
pressure  between  the  third  and  the  fourth.  Whitman 
has  drawn  attention  to  the  similarity  in  the  character 
of  this  pain  to  that  elicited  in  the  hand  by  compressing 
laterally  the  metacarpals  while  they  are  held  in  the  same 
plane,  and  are  not  allowed  to  form  the  carpal  arch. 
Tubby  has  twice  found  evidence  of  true  nerve  inflamma- 
tion. 

Diagnosis. —  The  pain  in  this  condition  is  charac- 
teristic: it  comes  on  suddenly,  sometimes  from  a  slight 
traumatism ;  is  sharp,  lancinating,  and  defined  to  the 
fourth  toe,  extending  down  to  its  tip  and  also,  fre- 
quently, up  the  leg,  following  the  nerve's  course.  The 
sufferer  may  be  compelled  to  remove  the  shoe  immedi- 
ately, and  will  instinctively  rub  the  forefoot,  compress 
and  relax  it,  and  flex  and  extend  the  toes.  It  may  be 
possible  to  replace  the  shoe  in  a  few  moments  and  be 
comfortable  until  another  traumatism,  perhaps  some 
particular  poise  or  step,  excites  it  again.  When  the  at- 
tacks become  frequent,  and  a  chronic  neuritis  results, 
the  slightest  pressure  causes  pain  so  that  walking,  espe- 
cially with  a  shoe,  is  almost  impossible. 

Examination. —  A  callus  may  be  found  beneath  the 


256 


DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


fourth  metatarsal  and  its  head  may  be  distinctly  beneath 
its  normal  plane.  The  base  of  the  fifth  metatarsal  may 
be  prominent  and  its  shaft  incline  inwards  toward  the 
fourth,  while  the  little  toe  is  directed  outward,  so  that 
the  base  of  the  first  phalanx  is  directed  inward  toward 
the  head  of  the  fourth  metatarsal. 


Fig,  87.  Callus  in  Morton's  Toe 
The  situation  of  this  callus  is  very  characteristic.  It  lies  beneath 
the  head  of  the  fourth  metatarsal  bone.  _  The  calluses  resulting 
from  a  shortened  heel-cord  are  usually  five  in  number,  lying  beneath 
the  heads  of  the  five  metatarsals.  There  is  present  in  the  above 
illustration  a  hallux  valgus  and  also  a  hammer  toe. 

Treatment. —  Sometimes  a  pad,  carefully  shaped 
and  applied  to  restore  the  transverse  arch,  and  strapping 
to  separate  the  bones  may  be  successful.  When  the  radio- 
graph shows  an  undoubted  impinging  on  the  head  of 


OTHER   AILMENTS  257 

the  fourth  metatarsal  by  the  third  metatarsal  or  by  the 
first  phalanx  of  the  little  toe,  an  excision  of  the  fourth 
metatarsal  head  may  be  undertaken.  It  is  a  simple 
operation  and,  aside  from  a  slight  retraction  of  the 
fourth  toe,  is  not  followed  by  any  bad  results.  Re- 
section has  been  done  of  other  metatarsal  heads  with 
reported  cures.  On  the  other  hand  it  is  easy  to  be  de- 
ceived by  the  radiograph  and  to  give  an  excellent  prog- 
nosis, only  to  reap  disappointment,  an  unfortunate 
experience  which  I  once  had.  It  is  now  my  custom  to 
withhold  operation  until  all  other  means  of  cure  have  been 
exhausted. 

An  operation  has  been  devised  and  practiced  by  Forbes 
which  consists  of  a  transplantation  of  the  extensor  tendon 
of  the  fourth  toe  into  the  head  of  the  metatarsal. 

HALLUX   VALGUS 

This  is  a  condition  in  which  the  great  toe  is  directed 
in  toward  the  middle  line  of  the  foot  and  toward  the 
other  toes,  and  the  first  metatarsal-phalangeal  joint  is 
made  prominent  on  the  foot's  inner  border. 

Etiology. —  Its  most  frequent  cause  is  the  crowding 
together  of  the  toes  in  a  narrow-toed  shoe.  After  the 
deformity  has  started,  a  short  shoe  will  increase  it  by 
pressing  backward  against  the  tip  of  the  toe  and  crowd- 
ing the  head  of  the  first  metatarsal  outward  from  the 
middle  line  of  the  foot.  The  extent  of  the  deformity 
may  vary  from  a  slightly  abnormal  inclination  to  al- 
most a  right  angle  with  the  other  toes,  so  ^that  the  great 


258         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

toe  may  lie  upon  and  across  the  others.  A  bursa,  called 
here  a  bunion,  develops  on  the  side  \oi  the  joint  where 
it  presses  against  the  side  of  the  shoe. 

The  loss  of  the  normal  function  of  this  toe  precludes 
proper  walking  and  the  prevention  and  cure  of  this 
deformity  is  therefore  of  great  importance.  Shoes 
likely  to  cause  it  should  be  unhesitatingly  condemned 
even  if  otherwise  perfect. 


Fig.  88.  Hallux  Valgus 
The  great-toe  is  turned  inward  toward  the  middle  line  of  the 
foot.  The  cause  in  this  case  was  paralysis.  When  due  to  faulty 
foot-wear  the  deformed  toe  usually  lies  above  the  other  toes  and 
the  metatarsal  head  is  made  very  prominent  by  pressure  outward, 
toward  the  other  foot,  through  the  phalanges. 

Treatment. — ^  When  the  deformity  is  slight  and  the 
toe  can  easily  be  brought  by  passive  movement  to  its 
normal  position,  exercises,  manipulations,  and  correct 
foot-wear  may  be  all  that  is  needed.  But  the  detail  of 
such  treatment  must  receive  conscientious  attention  to 
be  effective.  At  night  a  brace  may  be  worn  to  retain 
the  toe  in  a  straight  position.  A  piece  of  steel  spring, 
secured  along  the  inner  border  of  the  foot  by  straps 
and  having  a  strap  to  hold  the  toe  against  it,  will  be  all 
that  is  demanded. 


OTHER   AILM'ENTS  259 

Various  braces  have  been  made  designed  for  wear 
in  the  shoe.  Perhaps  the  most  popular  device  is  a  stall 
made  by  inserting  a  small  piece  of  steel  through  an  in- 
sole so  that  it  will  press  against  the  side  of  the  toe  and 
hold  it  in  a  straight  position.  An  insole  is  obtained 
which  fits  the  shoe  accurately,  the  foot  is  placed  upon 
it,  and  the  cleft  marked  between  the  first  and  second 
toes.  A  piece  of  light  steel  (tin  is  satisfactory)  is  cut 
so  as  to  be  one-half  inch  longer  than  double  the  depth 
of  the  toe,  the  height  of  the  top  of  the  toe  from  the 
ground,  and  of  a  width  equal  to  the  length  of  the  first 
phalanx.  This  is  doubled  upon  itself,  on  its  long  di- 
ameter, and  the  ends  for  the  last  quarter  of  their  lengths 
bent  at  right  angles  to  make  flanges.  The  end  of  the 
contrivance  will  now  have  the  shape  of  an  inverted  T 
with  the  stem  having  two  layers  and  the  flanges  one 
each.  This  stall  is  then  pressed  through  a  slot  made 
in  the  sole  at  the  place  marked  as  the  site  of  the  cleft, 
the  flanges  coming  against  the  bottom  of  the  inner-sole 
and  holding  the  stall  in  place.  The  stall  had  better  be 
covered  with  a  little  padding  which  may  be  secured  by 
adhesive  plaster.  If  the  stall  is  not  high  enough  the 
toe  will  at  times  get  above  it  and  cause  severe  pain. 
This  method  is  only  practical  in  moderately  deformed 
cases,  where  the  deformity  is  easily  corrected  by  manipu- 
lation. 

Wedges  made  of  cotton  may  be  used  to  separate  the 
first  and  second  toes  and  together  with  other  treatment, 
especially  exercises,  will  be  of  assistance. 


26o 


DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


Operation. —  When  the  deformity  is  of  long  stand- 
ing, bony  changes  and  shortening  of  the  soft  structures 
on  the  inner  side  of  the  joint  will  make  an  operation 
imperative.  This  is  best  done  by  a  curved  incision 
around  the  bursa  with  the  base  downward;  careful 
dissection  of  the  flap  off  from  the  bursa,  a  second  in- 


FiG.  89.    Operation  for  Hallux  Valgus 
The  solid  line  represents  the  skin   incision,  the  interrupted  line 
the  incision  for  the  flap  containing  the  bursa,  which   is  turned  in 
between  the  metatarsal  and  the  phalanx,  after  removal  of  the  head 
of  the  former. 


cision,  forming  a  flap  with  its  base  forward  and  includ- 
ing the  bursa ;  removal  of  the  head  of  the  metatarsal  in 
a  line  not  directly  at  right  angles  to  the  long  axis  of  the 
bone,  but  extending  outward  and  slightly  forward; 
making  the  end  of  the  bone  smooth  with  the  rongeur: 
placing  the  bursa  in  the  resected  joints  and  securing  with 


OTHER    AILMENTS  261 

a  suture;  closing  the  wound  and  applying  a  plaster-of- 
Paris  dressing  with  the  great  toe  in  the  straight  or 
slightly  abducted  position.  A  movable  joint  may  be 
expected  as  a  result. 

Objection  to  the  operation  has  been  made  on  the 
score  that  removal  of  the  head  of  the  first  metatarsal 
takes  away  an  important  support  of  the  forefoot.  How- 
ever, no  unfavorable  results  have  been  reported,  and,  on 
the  other  hand,  C.  H.  Mayo  reports  (Annals  of  Surgery) 
sixty-five  operations,  all  of  which  were  most  satisfactory. 

HAMMER-TOE 

When  one  of  the  smaller  toes  has  become  flexed  at 
its  first  inter-phalangeal  joint,  so  that  this  joint  stands 
up  prominently  above  the  plane  of  the  other  toes,  and 
is  not  extensible  even  by  passive  movement,  it  is  called 
a  hammer-toe. 

Etiology. — It  is  caused,  in  the  last  instance  at  least, 
by  the  toe's  being  retained  in  this  position  continuously 
by  the  crowding  together  of  the  other.  The  chief 
reason  for  its  exciting  any  complaint  is  that  the  summit 
of  the  flexed  joint  is  subject  to  pressure  against  the 
shoe  leather  and  a  painful  corn  is  usually  the  result. 

Treatment. — If  not  of  too  long  standing,  the  pre- 
scribing of  proper  foot-wear  and  of  exercises  for  the 
toes,  may  relieve  the  condition.  The  upper  of  the  shoe 
over  the  toes  should  be  of  sufficient  room  to  avoid  pres- 
sure on  the  joint;  a  soft  leather  will  be  less  irritating 
than   a   stiff   leather.     A   simple   arrangement   may  be 


262         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

made  to  hold  the  toe  extended  by  strapping  it  down 
to  an  inner  sole,  the  straps  running  through  slots  opposite 
the  cleft  on  either  side  of  the  deformed  toe. 

Operation. —  In  cases  of  long  standing,  however, 
success  is  not  likely  to  be  achieved  by  any  means  short 
of  an  operation.  Simple  division  of  the  contracted  soft 
tissues,  followed  by  retention  of  the  toe  in  the  straight 
position  for  two  weeks,  will  be  all  that  is  needed,  unless 
there  have  been  marked  bony  changes.  The  contracted 
structures  are  usually  the  lateral  ligaments  and  some- 
times the  plantar  ligament.  All  three  may  be  divided 
through  a  small  puncture  on  one  side.  If  the  joint 
is  much  altered  in  shape  the  extension  made  possible 
by  dividing  the  tissues  on  the  flexor  side  can  not  be 
expected  to  remain  permanent.  Under  such  circum- 
stances a  resection  of  the  joint  is  better  when  an  opera- 
tion has  been  undertaken. 

Raynaud's  disease 

Usually  a  symptom  of  some  disease  affecting  the 
nervous  system,  Raynaud's  disease  may,  rarely,  exist 
without  any  such  connection.  It  may  affect  any  of  the 
extremities  or  even  other  parts  of  the  body.  It  is  most 
frequently  seen  in  middle  life,  attacking  women  more 
often  than  men.  It  is  not  always  symmetrical,  although 
this  was  at  one  time  considered  one  of  its  characteristics. 
If  symmetry  is  present  it  is  the  more  easily  diagnosed. 
There  are  three  stages,  the  first  and  second  coming  in 
paroxysms;    local    syncopy,    local    cyanosis,    and    local 


OTHER   AILMENTS  263 

gangrene.  The  disease  may  present  the  symptoms  of 
the  second  stage  without  those  of  the  first  having  been 
present  or  at  least  without  the  symptoms  having  been 
recognized. 

In  the  stage  of  syncopy,  caused  by  spasm  of  the 
arterioles,  the  part,  usually  the  plantar  surface  of  the 
toes,  becomes  white  and  cold  and  there  is  present  a 
disturbance  of  sensation.  It  may  be  brought  on  by 
exposure  to  a  low  temperature,  not  necessarily  a  very 
cold  temperature,  or  by  walking  or  standing.  It  is 
attended  with  pain  which  may  not  be  severe,  but  is,  in 
some  cases,  excruciating.  Warmth  and  rest  may  restore 
the  part  to  its  normal  condition.  The  disease  may  ex- 
press itself  only  in  these  attacks  of  the  first  stage  and 
may  not  progress  to  the  second  stage.  At  any  time 
it  may  be  arrested  and  not  return  for  months  or  even 
years. 

The  second  stage,  that  of  local  asphyxia,  usually  fol- 
lows the  first.  It  is  caused  by  spasm  of  the,  venules. 
The  part  becomes  blue  or  purple,  cold  and  edematous. 
Pain  may  vary  as  in  the  first  stage. 

The  third  stage,  which  does  not  follow  in  every  case, 
is  that  of  gangrene.  This  results  in  a  mummification 
of  the  part. 

Treatment. —  Anything  which  will  help  to  correct 
the  condition  of  the  vasomotor  system  will  help  to 
prevent  the  attacks  and  to  produce  a  cure.  General 
hygienic  treatment,  tonics,  and  equable  temperature  are 
of  great  value.     When  gangrene  is  present,  care  should 


264         DISEASES    AND   DEFORMITIES    OF   THE    FOOT 

be  taken  against  infection.  The  line  of  demarkation 
should  be  awaited  before  active  interference  is  under- 
taken. 

MYASTHENIA   ANGIO-SCLEROTICA.       INTERMITTENT 
CLAUDICATIO.       INTERMITTENT    LIMPING 

This  is  a  rare  condition  in  which  a  severe,  spon- 
taneous, cramp-like  pain  occurs  in  the  calf  while  walk- 
ing. A  moment's  halt  relieves  the  pain,  walking  is 
resumed,  and  the  attack  returns.  There  is  present  a 
circulatory  disturbance  which  causes  a  feeling  of  cold- 
ness in  the  foot  accompanied  by  a  blanching  of  the 
skin.  Lovett  reports  the  absence  of  pulse  in  the  dorsalis 
pedis  and  in  the  posterior  tibial  arteries  in  two  of  his 
cases. 

Treatment. —  Codein,  given  in  small  doses  three 
times  a  day,  has  been  highly  reported.  If  syphilis,  dia- 
betes, or  chronic  alcoholism  exists  appropriate  treatment 
may  alleviate  the  local  condition. 

PERFORATING   ULCER    OF    THE    FOOT 

This  is  a  neuropathic  ulcer  occurring  in  the  sole,  usually 
in  the  metatarsal  region,  painless,  and  showing  no  tend- 
ency to  heal.  Other  stigmata  of  the  nervous  condition 
underlying  the  ulcer  may  be  also  found  in  other  parts 
of  the  body,  such  as  the  condition  of  the  skin  and  nails 
of  the  hands.  It  may  be  associated  with  either  a  periph- 
eral neuritis  or  with  some  central  lesion.  The  ulcer 
is  usually  neglected  on  account  of  its  analgesic  condition 


OTHER    AILMENTS  265 

and  may  be  an  eighth  or  a  quarter  of  an  inch  in  diameter 
before  treatment  is  sought  and  may  reach  to  and  involve 
the  bonel  The  callous  formation  about  the  ulcer  may 
lead  to  the  diagnosis  of  an  infected  corn. 

Treatment. —  The  underlying  condition  should  be 
sought  for  and  appropriately  treated.  Local  treatment 
consists  in  thoroughly  cleansing  the  v^ound,  using  the 
curette  freely,  and  lightly  packing  and  dressing.  A 
mildly  stimulating  antiseptic  may  be  of  value.  Balsam 
of  Peru  mixed  with  castor  oil  is  to  be  recommended. 

PERNIO.       CHILBLAINS 

This  is  a  condition  of  disturbance  of  the  circulation  to 
a  part  and  results  from  prolonged  exposure  to  moderate 
cold.  The  skin  assumes  a  purplish  color  and  there  may 
be  edema.  The  subjective  symptoms  are  a  burning 
pain  with  itching.  A  foot  which  is  partly  or  completely 
paralyzed  is  very  subject  to  chilblains.  Anemia  is  a 
predisposing  factor.  According  to  Wright  there  is 
present  in  people  who  suffer  from  this  condition  a  de- 
ficiency of  the  calcium  salts. 

Treatment. —  This  consists  in  the  prevention  of 
exposure  to  cold.  Woolen  stockings  should  be  worn 
in  cold  weather.  The  burning  and  itching  may  be  re- 
lieved by  the  application  of  cooling  lotions,  as  a  fifty 
per  cent,  solution  of  alcohol.  If  the  skin  becomes  broken 
from  scratching,  infection  must  be  guarded  against. 
Internal  treatment  should  be  directed  against  anemia  if 
such  exists.     Calcium  is  reported  to  be  a  specific  and 


266         DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

may  be  given  as  the  lactate  or  the  chloride.  It  has  been 
recommended  that  its  administration  be  commenced  at 
the  beginning  of  cold  weather  and  continued  for  several 
weeks  in  cases  of  recurring  chilblains. 

CONGELATION.       FROST-BITE 

This  is  the  effect  of  a  prolonged  exposure  to  a  severe 
cold.     The  diagnosis  is  not  difficult. 

Treatment. —  The  generally  accepted  plan  of  treat- 
ment is  the  gradual  restoration  of  the  circulation  by 
massage  with  snow  or  cold  water.  It  is  the  opinion 
of  some  surgeons  that  a  too  sudden  raising  of  the 
temperature  results  in  a  paralysis  of  the  muscular  coats 
of  the  vessels.  Doubtless  the  slow  restoration  of  the 
circulation  is  much  less  painful,  but  it  is  not  satisfactorily 
proved  that  gangrene  is  any  the  less  likely  to  occur. 
The  foot  should  not  be  kept  continually  moist  for  days, 
but  after  thirty-six  or  forty-eight  hours  should  be  dried, 
powdered  with  boric  acid,  wrapped  in  wool,  and  placed 
in  an  elevated  position.  If  gangrene  sets  in,  the  line 
of  demarkation  should  be  awaited  before  the  knife  is 
used.     Bullse  should  be  treated  as  they  are  in  burns. 

HYPERIDROSIS.       EXCESSIVE   SWEATING 

When  this  condition  attacks  the  feet  it  may  prove  to 
be  a  most  disagreeable  and  troublesome  affection.  Not 
only  the  stockings  but  the  shoe-leather  as  well  become 
damp  and  a  pungent  and  penetrating  odor,  "  bromid- 
rosis,"   is  created,   due  to  bacterial  growth.     There  is 


OTHER   AILMENTS  267 

present  a  functional  disease  of  the  sweat  glands  of  the 
feet,  the  cause  of  which,  except  that  it  is'  probably  of 
nervous  origin,  has  not  been  determined. 

Treatment. —  Mild  cases  may  demand  nothing  more 
than  a  change  of  stockings  twice  a  day  and  the  applica- 
tion of  a  powder  made  up  of  equal  parts  of  boric  acid 
and  salicylic  acid.  If  the  shoes  are  damp  when  the 
stockings  are  changed  another  pair  should  be  put  on. 
When  only  the  soles  of  the  shoes  are  damp,  the  use  of 
cork  insoles  may  answer  the  purpose,  a  fresh  pair  being 
inserted  whenever  the  stockings  are  changed.  It  will 
generally  be  found  that  these  patients  are  in  the  habit 
of  frequently  bathing  their  feet  in  very  hot  water,  their 
object  being  to  keep  their  feet  odorless.  It  is  much 
better  to  bathe  the  feet  in  cold  water  or  better  still  to 
douche  them  with  alternately  hot  and  cold  water,  then 
dry,  rub  with  alcohol  and  powder.  In  severe  cases 
Hebra  used  an  ointment  made  of  lead  plaster  and  olive 
oil.  This  he  applied  on  strips  of  linen  after  the  feet 
had  been  thoroughly  washed.  This  dressing  is  not  dis- 
turbed for  twenty-four  hours  when  fresh  ointment  is 
applied  without,  however,  again  washing  the  feet.  If 
necessary  this  procedure  is  kept  up  for  a  week  or  even 
two  when  the  epidermis  comes  off  in  large  plates.  The 
feet  are  then  washed  and  treated  with  boric  acid  powder. 
Careful  strapping  of  the  feet  with  zinc  oxid  plaster  is 
much  easier  to  apply  and  is  very  gratifying  in  its  re- 
sults. 

The  general  condition  of  the  patient  should  receive 


268  DISEASES    AND    DEFORMITIES    OF   THE   FOOT 

attention  at  the  same  time  as  the  feet,  as  most  of  these 
patients  will  be  found  to  be  run  down  and  more  or 
less  anemic  and  nervous. 

ERYT  H  RO  M  ELALGI A 

A  chronic  disease  in  which  there  is  a  painful  conges- 
tion of  the  feet  and  to  a  less  extent  of  the  hands.  It 
is  at  first  limited  to  the  heel,  or  perhaps  to  the  forefoot 
and  occurs  only  at  night  but  finally  extends  over  the 
entire  plantar  surface  and  is  present  night  and  day. 
When  it  has  progressed  to  this  stage  walking  or  even 
standing  becomes  very  painful. 

PLANTAR   NEURALGIA 

Erythromelalgia  is  considered  by  Dana  as  a  form  of 
plantar  neuralgia.  He  states  that  in  rare  cases  the  pain 
of  sciatica  is  limited  to  the  plantar  nerves  and  is  ac- 
companied by  anesthesia  and  paresthesia  of  this  region. 
It  may  be  present  in  insular  sclerosis,  tabes  dorsalis,  and 
myelitis. 

CLAVUS.      CORNS 

The  skin  is  being  constantly  renewed  by  the  multi- 
plication of  its  deeper  cells  and  the  shedding  of  its 
external  ones.  The  new  cells  push  the  older  ones  up- 
ward into  the  outermost  layer  of  the  epidermis,  the  horny 
layer  or  stratum  corneum,  whence  they  are  cast  off.  If 
pressure  is  exerted  against  an  area,  these  cells  are  not 
only  prevented  from  escaping  ahead  of  those  pushing 


OTHER   AILMENTS  269 

them  outward;  but,  if  the  pressure  continues,  they  are 
crowded  back  into  a  compact  mass.  The  cells  pile  up 
and  spread  out  beneath  the  point  of  pressure;  and  in 
consequence  a  cone-shaped  mass  is  fonned,  the  apex 
being  in  the  deep  layer  and  the  base  on  the  external 
surface.  It  is  thus  that  a  corn  is  formed.  Its  apex, 
pressed  in  among  the  papillae  which  are  extremely  abun- 
dant in  nerves,  causes  the  pain  which  is  an  accompani- 
ment of  all  corns.  When  this  external  pressure  is  made 
by  an  adjoining  toe  the  outer  layer  of  the  corn  is  kept 
moist  and  thus  a  "  soft  corn  "  is  formed.  If  the  pres- 
sure is  intermittent  as  is  more  frequently  the  case  in 
the  sole  of  the  foot,  calluses  are  produced.  These, 
while  causing  the  piling  up  of  the  outer  layer,  do  not  so 
confine  the  cells  as  to  form  the  distinct  hard  cone  seen 
in  the  veritable  corn.  In  the  formation,  therefore,  a 
corn  is  first  a  callus  and  later,  as  the  pressure  continues, 
the  cells  become  more  and  more  compact  so  that  a  dense 
center  column,  the  core,  is  formed. 

A  corn  is  always  the  result  of  pressure  and  much 
valuable  information  in  the  diagnosing  of  foot-deformi- 
ties can  be  obtained  by  noting  the  location  of  a  corn. 
It  is  quite  essential  to  bear  in  mind  that  although  the 
patient's  foot  may  be  in  otherwise  perfect  physical  con- 
dition, and  the  pressure  may  be  caused  by  an  ill-designed 
shoe;  on  the  other  hand  the  shoe  may  be  designed  for 
a  perfect  foot  and  be  of  a  correct  size;  but  owing  to 
some  faulty  condition  of  the  foot,  as  will  be  the  case 
if  it  is  held  in  abduction,  the  skin  will  be  pressed  un- 


270         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

duly  against  the  leather.  Spasm  of  the  peronei  will 
SO  abduct  the  fore-foot  that  pressure  will  be  exerted 
opposite  the  head  of  the  fifth  metatarsal  regardless  of 
what  shape  shoe  is  worn.  A  short  shoe  with  a  narrow 
toe  cannot  fail  to  crowd  one  or  more  of  the  toes  into 
flexion  causing  the  skin  over  the  proximal  interpha- 
langeal  joint  to  press  against  the  leather  and  produce 
a  corn.  Thus  a  hammer-toe  frequently  has  a  corn  over 
this  joint.  If  a  hallux  valgus  is  present  a  short  toe 
will  press  the  toe  backward  and  outward  so  as  to  crowd 
the  head  of  the  first  metatarsal  against  the  leather  of 
the  shoe.  As  a  hallux  valgus  interrupts  the  symmetry 
of  the  inner  line  of  the  foot  and  shoes  are  not  usually 
made  to  accommodate  this  bulging  joint,  there  is  pres- 
sure here  even  in  a  shoe  of  ample  length  and  a  corn  in 
this  condition  is  almost  invariably  present. 

In  some  cases  it  may  be  noted  that  the  skin  seems 
to  produce  corns  with  extraordinary  facility  and  will 
not  tolerate  pressure  which  would  cause  no  disturbance 
in  other  cases. 

In  pityriasis  rubra  pilaris  corns  are  easily  formed. 

Diagnosis. —  A  small  perforating  ulcer  has  a  callus 
about  it  and  may  easily  be  mistaken  for  a  corn,  a  mis- 
take which  can  be  avoided  if  this  fact  is  kept  in  mind 
during  the  examination. 

Treatment. —  It  hardly  need  be  pointed  out  that 
the  removal  of  the  cause  is  essential.  We  know  that 
the  cause  is  the  pressure  of  the  skin  against  the  leather 
and  the  removal  of  pressure  may  be  obtained  by  stretch- 


OTHER    AILMENTS  2/1 

ing  the  leather  or  cutting  it  away,  proceedings  fre- 
quently resorted  to  by  the  patients  themselves.  The 
rings  of  felt  sold  in  the  drug-stores  for  this  purpose  are 
generally  efficient.  Some  shoe-makers,  when  hallux 
valgus  is  present,  make  a  ring  of  leather  with  wings 
or  extensions  extending  forward  and  backward,  which 
when  placed  in  the  shoe  not  only  prevent  pressure  but 
hide  the  deformity  quite  effectually.  All  of  these  meas- 
ures are  but  palliative:  they  recognize  pressure  as  the 
cause,  but  do  not  remove  the  cause  of  the  pressure. 

If  an  on-coming  deformity,  such  as  a  beginning  flat- 
foot  or  hallux  valgus,  is  found  or  if  a  deformity  al- 
ready exists,  appropriate  treatment  should  be  directed 
toward  the  correction  of  such.  The  shoes  must  be 
changed  if  they  are  too  short  or  too  narrow  or  if  they 
hold  the  forefoot  abnormally  abducted  or  adducted. 

To  remove  the  corn,  it  should  first  be  softened.  This 
may  be  done  by  soaking  the  foot  in  a  hot  bath  for 
twenty  minutes  and  then  drying  the  foot  and  applying 
salicylic  acid.  Salicylic  acid  acts  chemically  upon  the 
callus,  softening  it  so  as  to  facilitate  its  removal.  It  may 
be  put  up  in  flexible  collodion,  five  grains  to  the  ounce, 
and  painted  on  with  a  camel's  hair  brush;  or  it  may  be 
applied  in  the  form  of  an  ointment  made  up  of  lanoline 
and  vaseline,  five  parts  of  each  and  one  part  of  salicylic 
acid.  In  ten  or  twelve  hours  the  softened  callus  appears 
as  a  white  mass  and  can  be  picked  off.  It  may  be  neces- 
sary to  repeat  the  treatment,  perhaps  two  or  three  times 
before  the  last  vestige  of  the  corn  is  removed.     Naturally, 


272         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

if  the  original  pressure  is  operative  after  each  treat- 
ment, the  corn  will  return  and  the  above  procedure  will 
have  to  be  repeated  indefinitely. 

There  are  two  corns  which  deserve  special  mention: 
the  soft  corn  and  the  corn  over  an  hallux  valgus.  The 
soft  corn  can  be  effectually  treated  by  the  process  as 
above  described  and  then  by  placing  a  pledget  of  cotton 
between  the  toes.  A  broad-toed  shoe  is  essential  for 
a  cure.  The  corn  accompanying  a  hallux  valgus  will 
often  have  a  bursa  developed  beneath  it.  This  corn 
is  more  subject  to  inflammation  than  any  other  and 
it  is  frequently  called  a  bunion.  The  treatment  quite 
commonly  resorted  to,  of  paring  it  with  a  knife,  may 
result  in  an  infection  and  a  serious  condition  thereby 
be  produced.  When  infection  is  present  half-way  meas- 
ures must  not  be  tolerated.  The  patient  must  remain 
indoors  to  the  end  that  appropriate  treatment  can  be 
carried  out.  It  may  be  sufficient  to  apply  hot  boric  acid 
dressings,  under  oiled  silk,  the  dressing  being  large 
enough  to  cover  the  entire  forefoot;  or  more  radical  pro- 
cedure may  be  demanded,  such  as  opening  and  draining. 
As  the  bursa  beneath  this  corn  communicates  with  the 
metatarsal-phalangeal  joint,  neglect  or  improper  treat- 
ment may  prove  to  be  a  rather  serious  matter. 

ONYCHIA.       PARONYCHIA.       INGROWING     TOE-NAIL 

This  is  an  inflammation  of  the  matrix  and  the  soft 
parts  about  the  nail.  Paronychia  of  the  toes  is  most 
frequently  found  on  the  large  toe  and  is  commonly  called 


OTHER   AILMENTS 


273 


ingrowing  toe  nail.  It  is  caused  by  the  pressure  of 
the  shoe  against  the  side  of  the  toe,  forcing  the  soft 
parts  against  the  nail  which  may  have  an  abnormally 
sharp  edge,  usually  from  careless  trimming.  The  soft 
parts  become  inflamed  and  swollen  and  a  painful  con- 
dition exists. 

Treatment. —  This  must  depend  upon  the  severity 


Fig.  go.    Conservative  Treatment  of  Ingrovv^ing  Toe-Nail 
The  irritation  from  the  nail  is  relieved  by  a  pledget  of  cotton  and 
the  exuberant  tissue  is  drawn  away  by  a  strip  of  adhesive  plaster. 

of  the  case  and  the  control  one  can  expect  to  have  over 
the  patient.  In  dispensary  patients  radical  measures  are 
the  most  satisfactory.  When  time  is  not  of  importance, 
operation  is  seldom  necessary.  Moreover,  in  private 
practice  this  condition  is  apt  to  be  called  to  the  surgeon's 
attention  in  its  early  stages.  Conservative  treatment 
consists  first  in  removing  all  pressure  such  as  may  be 
caused  by  a  pointed  or  narrow  shoe  or  even  by  a  narrow 
or  short-toed  stocking,  and  then  in  removing  the  irrita- 


274         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

tion  caused  by  the  pressure  of  the  side  of  the  nail.  This 
last  may  be  done  by  pressing  a  little  piece  of  cotton  with 
a  probe  or  an  orange  wood  stick  or  a  pointed  match 
under  the  edge  of  the  nail  and  between  it  and  the  swollen 
parts.  The  soft  parts  may  be  further  relieved  by  draw- 
ing them  away  from  the  nail  with  a  narrow  strip  of 
adhesive  plaster  encircling  the  toe.  When  conservative 
treatment  is  undertaken  the  patient  should  be  instructed 
to  trim  the  nail  straight  across  and  not  to  cut  down 
the  corner  or  inner  edge. 

Radical  treatment  consists  in  the  removal  of  the  sharp 
edge  of  the  nail.  About  a  third  of  the  nail  should  be 
taken  off  together  with  that  part  of  the  matrix  and  the 
swollen  soft  part.  It  can  readily  be  done  under  a  local 
anesthetic.  A  rubber  tube  is  first  fastened  about  the 
base  of  the  toe  and  cocaine,  if  that  is  used,  is  injected 
around  the  nail.  The  first  thrust  of  the  needle  should, 
cause  all  the  pain  there  is  to  bear.  The  incision  should 
be  elliptical,  including  all  that  is  to  be  removed.  Horse 
hair  sutures  are  the  best  for  closing  the  wound.  The 
edges  will  not  be  brought  close  together;  but  there  will 
be  less  surface  to  granulate,  the  time  of  healing  will 
be  shortened;  and  the  co-aptation  of  the  V-shaped  de- 
pression left  in  the  soft  parts  by  the  removal  of  the 
exuberant  tissue  will  the  better  insure  a  rapid  cure. 

Should  the  toe  be  acutely  inflamed  and  very  painful  it 
may  be  better  to  defer  operation  until  the  condition  has 
been  rendered  less  acute  by  a  few  days'  treatment  with 
rest  and  wet  dressings. 


OTHER   AILMENTS  275 

CALLUS.       CALLOSITES 

Callus  will  appear  wherever  the  skin  is  subjected  to 
constant  irritation.  When  on  the  feet  it  is  due  to  de- 
formities, faulty  mechanism  in  the  use  of  the  feet,  ir- 
ritation from  foot-wear,  or  the  presence  of  one  of  two 
diseases.  If  the  callus  is  of  long  standing,  a  bursa  may 
be  developed  beneath  it,  as  is  frequently  found  beneath 
the  callus  over  the  cuboid  in  a  much  used  talipes  equinus 
varus. 

Frequently  the  location  of  the  callus  and  its  extent 
and  hardness  are  guides  to  the  condition  of  the  foot. 
Calluses  under  the  heads  of  the  five  metatarsals  are  evi- 
dence of  a  complete  lowering  of  the  transverse  arch 
and  will  be  found  in  non-deforming  club-foot  of  long 
standing  and  also  in  cases  of  anterior  metatarsalgia.  If 
the  callus  is  under  the  head  of  only  one  metatarsal,  usu- 
ally the  fourth  or  third,  the  condition  found  in  Morton^s 
toe  is  present. 

There  are  two  diseases  which  may  be  accompanied 
by  calluses  of  the  soles;  ichthyosis  and  pityriasis  rubra 
pilaris. 

Treatment. —  The  cause  of  the  irritation  must  be  de- 
termined and  dealt  with  accordingly.  The  callus  may 
be  removed  by  the  treatment  laid  down  for  corns,  or 
it  may  be  left  to  desquamate,  as  it  will  if  the  cause  of  its 
inception  is  eradicated. 


276         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 
PAINFUL   SOLES 

Pain  in  the  sole  of  the  foot  may  be  present  with  any 
of  the  following  conditions :  deformities,  new  growths, 
contractions,  scar  tissue,  absorption  of  fat  from  pres- 
sure or  following  prolonged  illness,  gout,  rheumatism, 
arthritis  deformans,  inflammatory  arthritis,  as  tubercu- 
lous or  gonorrheal,  Raynaud's  disease,  erythromelalgia, 
plantar  neuralgia. 


CHAPTER  XI 
FOOT-APPAREL 

It  is  quite  generally  admitted  that  many  deformities 
of  the  foot  are  due  to  faulty  clothing.  Some  French 
surgeons,  to  be  sure,  have  recently  taken  pains  to  dis- 
count this  opinion,  claiming  that  some  pathological  con- 
dition of  muscles,  nerve,  or  joint  is  the  primary  etio- 
logical factor  and  that  the  shape  of  the  foot-clothing 
is  of  but  secondary  importance. 

"  Without  wishing  to  ignore  the  role  played  by  mal- 
constructed  shoes  in  the  production  of  deformities  of 
the  toes,  it  seems  to  us  that  such  causes  ought  to  be 
considered  as  accessories;  the  role  by  far  the  most  im- 
portant, it  seems  to  us,  appertains  to  general  causes, 
among  which  chronic  rheumatism  ought  to  have  first 
place."  * 

While  this  may  be  true  in  some  cases,  we  do  not  believe 
that  most  surgeons  agree  that  it  is  so  in  the  majority 
of  the  deformities  of  the  foot. 

Stockings. —  A  stocking  so  short  as  to  prevent  full 
extension  of  the  toes  or  so  pointed  as  to  cause  adduction 
of  the  great  toe  and  of  the  two  outer  toes,  would  not 

*  Les  Difformites  des  Orteils.  Kirmisson  et  Baillene.  Revue 
D'Orthopedie.    ler  Mars,  1913. 

277 


-278         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

cause  a  permanent  deformity  were  it  worn  but  a  few 
hours  and  the  muscles  and  joints  properly  exercised  when 
freed  of  the  restraining  influence  of  the  stocking.  The 
gravity  of  the  restraint  of  a  confining  shoe  or  stocking 
is  due  to  the  prolonged  time  of  its  effect.  Improper 
walking  and  standing  have  so  trained  many  people  to 
use  the  foot  as  though  it  were  one  solid  mass  that  upon 
removing  the  shoes  and  stockings  they  will  walk  the 
little  that  is  necessary,  bare- footed  or  in  bed-room  slip- 
pers, go  to  bed,  and  dress  in  the  morning  without  having 
moved  the  toes  or  the  smaller  joints  of  the  foot  to  even 
the  smallest  extent. 

As  stockings  and  socks  are  made  of  flexible  and  elastic 
material,  their  influence  is  limited  to  that  of  compressing 
the  more  movable  joints,  especially  the  toes.  Digitated 
stockings  have  been  made  but  were  never  very  popular. 
"  Rights  and  lefts  "  are  on  the  market  and  are  to  be 
recommended  if  one  does  not  try  to  get  too  good  a  fit 
and  thereby  get  a  stocking  that  is  too  short.  The  ordi- 
nary stocking,  as  long  as  it  is  not  too  pointed  and  not 
too  short,  is  beyond  criticism.  Whether  it  should  be 
made  of  silk,  wool,  or  cotton  will  depend  upon  the  circu- 
lation of  the  foot. 

Shoes. —  A  great  many  attempts  have  been  made  to 
produce  a  perfect  shoe.  Shoemakers  have  been  at  no 
little  pains  to  turn  out  a  confection  of  their  art  which 
would  meet  the  scientific  requirements  as  they  have  under- 
stood them.  The  results  have  been  encouraging  al- 
though they  have  been  far  from  perfect.     As  soon  as 


FOOT-APPAREL  279 

it  has  been  definitely  decided  just  what  constitutes  a 
perfect  shoe,  a  long  step  ahead  will  have  been  taken. 
When  the  surgeons  are  finally  in  accord  on  this  subject 
it  is  not  probable  that  Dame  Fashion  will  be  able  to  ig- 
nore the  dicta  as  to  shoe-construction  as  laid  down  by 
Master  Science.  She  has  been  forced  to  bow  to  so 
many  laws  of  hygiene  that  we  hope  she  will  allow  her 
toes  to  be  stepped  on. 

As  it  is,  we  should  feel  pleased  at  the  advance  that  has 
been  made  in  the  styles  of  shoes  sold  in  the  markets 
to-day.  Orthopedic,  Common  Sense,  and  various  other 
named  shoes  have  a  constantly  increasing  sale,  showing 
the  desire  of  the  laity  to  treat  their  feet  with  becoming 
respect  and  not  to  be  too  much  the  slaves  of  the  passing 
whims  of  fashion.  Some  of  these  shoes  have  the  fore- 
foot so  adducted  that  the  outer  border  of  the  soles  form 
almost  a  quadrant  of  a  circle ;  some  have  simply  a  broad, 
square  toe;  some  an  extension  or  Thomas  heel;  some 
a  wedge-shaped  heel;  and  some  have  stiffening  of 
one  sort  or  another  under  the  dome.  Most  of  these 
modifications  have  their  therapeutic  value,  but,  for  the 
normal  foot,  some  of  them  are  likely  to  prove  to  be  in- 
jurious. 

The  first  requirement  of  a  shoe  for  a  normal  foot  is 
that  it  must  permit  the  free  functionating  of  the  foot. 
This  is  of  less  importance  if  the  foot  is  not  to  function- 
ate while  in  the  shoe;  but  as  most  shoes  are  used  for 
standing  and  walking,  we  need  not  consider  the  shoe 
worn  only  while  the  foot  is  at  rest. 


28o  DISEASES    AND    DEFORMITIES    OF    THE    FOOT 

Heels. — First  as  to  the  heel;  a  high-heel  is  injurious 
only  when  being  used.  The  greatest  objection  to  the 
high-heel  is  that  it  makes  it  so  difficult  to  walk  on  the 
toes.  Most  of  them  are  found  on  narrow,  pointed  shoes 
which  are  of  themselves  objectionable.  If  high-heels  are 
worn  constantly  they  may  also  be  a  contributing  factor 
to  non-deforming  club-foot.  Of  the  two  most  popular 
forms  of  high-heels,  that  which  has  its  supporting  surface 
the  more  anterior  is  the  better,  the  French,  rather  than 


Figs.  91-92.    The  French  and  Cuban  Heels 
The  heel  of  a  shoe  should  have  its  base  in  the  plane  of  gravity 
to  give  the  greatest  support.     If  it  is  behind  this  plane  it  may  be  a 
contributing  cause  of  vi^eakness  of  the  ligaments  and  muscles. 

the  Cuban  heel.  The  ideal  heel  is  not  higher  than  the 
sole,  has  straight  sides  and  extends  well  forward,  to 
the  plane  of  the  anterior  border  of  the  internal  malleolus, 
thus  giving  a  firm  and  extensive  support. 

Toe. — The  main  features  to  be  sought  in  the  toe  of 
the  shoe  are,  that  the  toes  have  room  to  extend  and  to 
flex ;  that  the  great  toe  has  room  for  abduction  and  rota- 
tion; that  the  metatarsals  are  not  cramped;  and  that  the 
forefoot  as  a  whole  is  not  held  in  abduction. 


FOOT-APPAREL  28 1 

As  a  cross  section  through  the  heads  of  the  meta- 
tarsals has  its  thickest  part  over  the  head  of  the  first, 
the  leather  covering  the  toe  of  the  shoe  should  not  offer 
the  most  room,  to  the  center  of  the  foot,  to  the  middle 
metatarsal,  as  is  so  often  the  case;  but  the  highest  part 
of  the  toe  of  the  shoe  should  be  over  the  great  toe.  A 
last  which  does  not  take  this  into  consideration  will  exert 


Fig.  93.  A  Faulty  Shoe-Toe 
Illustrating  the  evil  effect  of  the  inner  border  of  the  shoe,  at  the 
toe,  turning  inward  too  sharply.  This  shoe  does  not  increase  the 
deformity  of  the  great  toe  by  pressing  it  directly  inward,  but  by 
pressing  against  the  tip  in  a  direction  backward  and  inward.  This 
force  is  felt  at  the  first  metatarsal-phalangeal  joint  in  a  direction 
outward  and  backward;  the  direction  best  calculated  to  produce  a 
marked  hallux  valgus, 

an  adducting  force  on  the  large  toe  and  prevent  its  ab- 
duction and  rotation,  its  normal  movements. 

In  the  normal  foot,  the  line  connecting  the  middle  of 
the  tip  of  the  great  toe  with  the  center  of  the  first  meta- 
tarsal-phalangeal joint  will,  if  continued  backwards,  pass 
over  the  center  of  the  heel.  If  the  inner  side  of  the  great 
toe,  when  in  the  shoe,  can  for  its  entire  length  form  a 


282 


DISEASES    AND   DEFORMITIES    OF   THE   FOOT 


straight  line  with  the  inner  border  of  the  heel,  this  re- 
quirement is  met.  As  the  anterior  part  of  the  heel  of 
the  shoe  is  frequently  not  at  a  right  angle  to  the  long 
diameter  of  the  shoe,  care  must  be  taken  that  one  is  not 
thereby  deceived. 


Figs.  94-95.  The  Toe  of  the  Shoe 
The  sole  should  be  sufficiently  stout  to  prevent  its  being  curled 
up  at  the  sides.  The  space  within  should  be  ample  for  the  free 
functionating  of  the  metatarsals  and  the  phalanges.  The  figure  on 
the  right  shows  a  badly  fashioned  shoe-toe:  the  sole  curls  up  and 
the  greatest  depth  of  the  inside  measurement  is  in  the  center,  thus 
crowding  the  bones  together  and  forcing  the  third  metatarsal  onto 
a  lower  level. 


Fig.  96.  An  Excellent  Shoe 
The  heel  extends  forward  on  the  inner  side  and  also  further  in- 
wards than  is  usual.  Secure  support  is  thus  given  in  the  plane  of 
gravity  and  eversion  is  prevented.  There  is  ample  room  to  permit 
of  abduction  of  the  great-toe  and  also  to  provide  for  the  alterations 
in  the  shape  of  the  dome  of  the  foot  while  the  foot  is  function- 
ating.   It  is  not  unsightly. 

The  breadth  of  the  toe  should  be  such  that  the  toes 
can  be  fully  extended  and  flexed  as  easily  as  they  could 
be  were  one  wearing  sandals.  The  interference  with  this 
movement  is  the  greatest  cause  of  anterior  metatarsal- 
gia. 

Shank. —  The  waist  of  the  shoe  should  fit  snugly  and 


FOOT-APPAREL  283 

should  not  be  so  far  forward,  there  should  not  be  so  short 
a  vamp,  as  to  limit  movement  at  the  medio-tarsal  joint. 
The  shank  must  be  narrow,  for  if  wide  it  will  prevent 
the  leather  along  the  inner  side  from  being  laced  snugly 
up  against  the  longitudinal  arch.  The  shank  usually 
contains  a  steel  spring  which  undoubtedly  aids  in  pre- 
serving the  shape  of  the  shoe;  but  if  walking  is  properly 
done  and  if  the  heel  is  not  too  high,  it  is  unnecessary. 
Providing  it  is  not  so  long  as  to  obstruct  movement  at 
the  medio-tarsal  joint,  however,  there  can  be  but  little 
objection  to  it. 

The  importance  of  the  distance  of  the  part  of  the  sole 
beneath  the  first  metatarsal-phalangeal  joint  and  the  cen- 
ter of  the  heel,  has  been  pointed  out  by  Sampson.  If 
the  inner  border  of  the  sole  begins  to  curve  too  soon 
toward  the  shank,  the  upper  at  this  point  will  unduly 
press  against  the  head  of  the  first  metatarsal  and  will  not 
only  operate  against  the  normal  movement  of  the  great 
toe,  abduction  (away  from  the  middle  line  of  the  foot) 
and  rotation,  but  will  exert  an  abducting  force  on  the 
forefoot. 

Upper. — •  The  uppers  may  be  low,  the  "  shoe  "  of  the 
English,  or  high,  the  English  "boot."  The  low  shoe 
offers  more  freedom  to  ankle  movements  and  the  close 
fitting  high  tops  may  be  the  cause  of  a  certain  amount  of 
weakness.  If  high  shoes  are  worn  we  should  advise  that 
under  ordinary  circumstances  the  uppers  be  soft,  not  too 
stiff  and  unyielding,  and  never  reen forced  with  whale- 
bone or  other  material  unless  assuredly  indicated  by  some 


284         DISEASES   AND   DEFORMITIES    OF   THE   FOOT 

abnormal  condition.     A  lace  fastening  is  always  prefer- 
able to  any  other  kind. 

Rocker-sole. —  It  remains  to  say  a  word  regarding  the 
rocker-sole.  It  is  the  claim  of  shoemakers  that  if  the 
sole  is  made  to  lie  flat  on  the  ground,  especially  with  a 
low  heel,  it  will  be  turned  up  at  the  toe  after  it  has  been 
worn  a  short  while  and  not  be  so  presentable  as  a  shoe 
which  was  made  that  way  in  the  first  place.  To  a  great 
extent  this  is  true,  due  to  the  habit  of  heel-and-toe  walk- 
ing.    If  walking  consisted  in  rolling  onto  the  heel  and 


Figs.  97-98.    Rocker-Sole  and  Flat-Sole  Shoe 
The  former  is  the  shape  assumed  by  any  shoe,  with  a  low  heel, 
which  is  worn  by  a  heel-walker.    With  such  a  shoe  it  is  impossible 
to  walk  properly. 

off  the  toe,  the  rocker-sole  would  be  our  choice;  but  for 
the  normal  manner  of  walking  as  we  conceive  it,  the  toes 
should  bear  the  same  relation  to  the  rest  of  the  foot  while 
the  shoe  is  on  that  they  do  in  the  normal  barefoot, 
whether  walking,  standing,  or  resting. 

Fit. —  In  the  consideration  of  shoes,  it  is  well  to  re- 
member not  only  that  the  distance  across  the  metatarsals 
increases  during  standing,  due  to  the  abduction  of  the 
first  metatarsal  and  to  a  slight  lowering  of  the  metatarsal 
arch;  but  that  there  is  a  lowering  of  the  dome  as  a  whole. 


FOOT-APPAREL 


285 


This  may  be  demonstrated  by  marking  the  position  of 
the  tubercle  o£  the  scaphoid  and  observing  its  changed 

Figs.  99-100.    Alterations  in  the  Length  of  the  Foot  During 
Rest  and  Weight-Bearing 


During  rest:  the  foot  is  represented  as  7  inches  long  and  the 
scaphoid-tubercle  (imperfectly  marked)  as  2^  inches  above  the 
ground. 


Weight-bearing:  the  arch  is  lowered  as  shown  by  the  lowering 
of  the  tubercle  of  the  scaphoid,  and  the  foot  is  elongated  as  evi- 
denced by  the  toe  reaching  beyond  the  o  of  the  tape. 

relation  to  the  plane  of  the  sole  during  rest  and  during 
weight-bearing.     With  this  lowering  of  the  dome  there 


286         DISEASES    AND   DEFORMITIES    OF   THE   FOOT 

is  a  lengthening  of  the  foot,  which  may  be  read  on  a 
tape  measure  by  placing  it  under  the  weight-bearing  foot, 
taking  the  length  from  heel  to  tip  of  great  toe,  and  then 
with  the  foot  still  on  the  ground,  removing  the  weight 
by  having  the  subject  sit.  If  instead  of  removing  the 
weight,  the  subject  rises  on  tip-toe,  and  the  tape  is  brought 
up  to  the  heel,  it  will  be  found  that  the  foot  has  shortened. 


Fig.  ioi.    Alterations  in  the  Length  of  the  Foot  During  Tip- 
Toeing 

Tip-toeing :  the  foot  is  shortened  as  shown  by  reading  of  the 
tape,  due  to  the  elevation  of  the  arch.  The  tubercle  of  the  scaphoid 
is,  of  course,  raised. 

The  slight  flexion  of  the  great-toe  during  rest  and  its  position 
in  activity,  are  also  shown  in  these  illustrations. 

These  changes  in  the  length  of  the  foot  during  rest, 
weight-bearing,  and  tip-toeing,  are  only  what  would  be 
expected  from  the  lowering  and  raising  of  the  dome.  A 
slipper  which  fits  snugly  the  relaxed  foot,  will  be  too 
tight  when  standing  and  too  loose  when  on  tip-toe.  A 
comfortable  slipper  usually  flips-flaps  up  and  down  at  the 
heel  when  used  for  walking;  a  slipper  perfect  for  dancing 
is  uncomfortable  for  walking. 


INDEX 


Abductor  minimi  digiti,  37- 

poUicis,  37- 
Abscesses,  tuberculous,  240. 
Accessorius,  the,  33. 
Adams,  on  "club-foot,"  64. 
Adams  on  etiology  of  congeni- 
tal club-foot,  115. 
Adductor  poUicis,  38. 
Allison's    treatment    of    spastic 

paralysis,  181. 
Ankle     brace     for     tuberculous 

feet,  226. 
Ankle-joint  movement,  14,  43'  _ 
Apparatus  for  treating  congeni- 
tal club-foot,  130. 
for  treatment  of  infantile  par- 
alysis, 186. 
Arch  supporters,  92. 
Arthrodesis      of     astragalo-sca- 

phoid  joints,  107. 
Aspiration  for  gonorrheal  infec- 
tion of  the  foot,  246. 
Astragalo-scaphoid  capsule,  ten- 
otomy of,  168. 
Astragalectomy     for     congenital 
club-foot,  174- 
in  paralysis  of  foot,  213. 
Astragalus,  the,  13-16. 

Beely  shoe-heel,  88. 

Berg    on    causes    of    congenital 

club-foot,   116. 
Bessel-Hagen    on    frequency    of 

club-foot,  113. 
Bier's   treatment   of  tuberculous 

disease  of  the  foot,  231. 


Bone   operations    for   congenital 
club-foot,    172. 

Bones,    changes    in,    in    talipes 
equino-varus,    118. 
of  the  foot,  13. 

Bonnet's    classification    of    club- 
foot, 112. 

Brace,  Taylor's,  140. 

Braces  for  congenital  club-foot, 

131- 

for  foot  paralysis,  206. 

for  hallux  valgus,  259. 

for  tuberculous  feet,  226. 

for  weak-foot,  94r-96. 
Broadhurst  on  tenotomy,  171. 
Broca  on  astragalectomy,  175. 

Calcaneo-astragaloid  joint,  move- 
ments at,  45. 
Calcaneo-scaphoid  ligament,  23. 
Calcaneum,  the,  17. 
Calf  muscles,  24. 
Callosities,  275. 
Campbell  long  leg  brace,  227. 
Cavus,     accompanying    infantile 

paralysis,  195. 
Chilblains,  265. 
Clavus,  268. 
Claw-foot,  196. 

Club-foot,  Bonnet's  classification, 
112. 
causes,  bone  theory,  115. 
characteristics,     etiology     and 

treatment,  64-73. 
congenital,  iii-i77- 
causes,  germ  theory,  115. 


287 


INDEX 


Club-foot — Continued. 

causes,  nerve  theory,  115. 

causes,  pressure  theory,  115. 

causes,  theory  of  abnormal  fe- 
tal movements,  116. 

etiology  of,  114. 

frequency  of,  113. 

non-deforming,  64-110. 

pathology  after  use,  121. 
Congelation,  266. 
Congenital     club-foot,     adhesive 
plaster  for,  131. 

astragalectomy  for,  174. 

bone  operations  for,  174. 

braces  for,  131. 

felt  splints  for,  133. 

muslin  bandages  for,  130. 

pathology  after  use,  121. 

theories  of  causes,  114. 

varieties,   iii. 

wood  splint  for,  136. 
Congenital  deformities,  113, 

in  the  tibia  and  femur,  143. 
Coote,    Holmes,   on   "Joint   Dis- 
ease," 64. 
Corns,  268. 
Cuboid,  the,  17. 
Cuneiform  bones,  the,  18. 

Davis's  physiological  lavir,  157. 
Detmould  on  subcutaneous  ten- 
otomy, 161. 
Diagnosis  of  case,  59-63. 
of  tuberculous  foot,  217. 
of  w^eak-foot,  79. 
Diet,   for  tuberculous  foot,  238. 
Differential  diagnosis  of  tubercu- 
lous foot,  223. 
Dorsal  flexion  at  ankle  joint,  43. 
Douching  in  post-operative  treat- 
ment, 108. 
Duval,  E.,  on  tenotomy,  171 

Early    treatment    of    congenital 
club-foot,  125. 


Erythromelalgia,  268. 

Etiology  of  congenital  club-foot, 

114. 
Eschricht  on  causes  of  congeni- 
tal club-foot,  116. 
Exercises  for  flat-foot,  89. 
Extensor  brevis  digitorum,  39. 

longus  digitorum,  36. 

proprius  poUicis,  36. 
External  lateral  ligament,  22. 

Fallen  arch,  251. 
Felt  splint  for  congenital   club- 
foot, 133. 
Flat-foot — arthrodesis  operation, 
107. 

diagnosis,  83. 

osseous,  84. 

pathology  of,  85. 

Plaster  of  Paris  dressing  for, 
103. 

post-operative    treatment,    108. 

tarsectomy  for,  107. 

tenotomy  for,  106. 

treatment  of,  86. 
Flexor  brevis  digitorum,  33,  37. 

brevis  pollicis,  38. 

longus  digitorum,  32. 

longus  digitorum,  tenotomy  of, 
168. 

longus  pollicis,  28. 
Foot  at  rest,  48. 

bones  of,  13. 

ligaments  of,  21. 

muscles  and  tendons  of,  23. 

nerves  of,  39. 

standing,  49. 
Frequency  of  club-foot,  113. 
Frost-bite,  266. 

Galen    on    causes    of   congenital 

club-foot,  116. 
Gastrocnemius,    contraction    of, 

65. 


INDEX 


289 


Golding-Bird,  on  hollow-foot, 
196. 

Golding-Bird's  scaphoidectomy, 
108. 

Gonorrheal  infection  of  foot,  243. 

Great-toe  joint,  48. 

Guerin,  J,,  on  etiology  of  con- 
genital club-foot,  115. 

Hallux  valgus,  257. 

Hammer-toe,  261. 

Heel-and-toe  walking,  55. 

Heel-cord,  shortened,  treatment, 
250. 

Heliotherapy,  235. 

Hippocrates  on  causes  of  con- 
genital club-foot,  116. 

History  of  case,  59. 

Hoffa  on  causes  of  congenital 
club-foot,  116. 

Hollow  claw-foot,  196. 

Hyperidrosis,  266. 

Infantile     paralysis,      treatment, 

202. 
Ingrowing  toe-nail,  272. 
Injections  for  tuberculous  joints, 

242. 
Inspection  of  patient,  59. 
Intermittent  limping,  264. 
Internal  lateral  ligament,  22. 
Interossei,  the,  38. 

Ketch  on  congenital  deformities, 
113. 

Kirmisson  on  frequency  of  club- 
foot, 113. 
on   injections    for   tuberculous 

joints,  242. 
on     treatment     of     congenital 
club-foot,  146. 

Kocker  on  causes  of  congenital 
club-foot,  116. 

Lannelongue  on  frequency  of 
club-foot,  113. 


Lateral  traction  shoe,  203. 

Lechiberder  on  congenital  de- 
formities, 113. 

Ligaments,  changes  in,  in  talipes 
equino-varus,  120. 
of  the  foot,  21. 

Liniments,  109. 

Little  on  etiology  of  congenital 
club-foot,  115. 
on  subcutaneous  tenotomy,  161. 

Lumbricales,  the,  33. 

Lund,  on  astragalectomy,  174. 

Manipulations  for  weak-foot  and 
flat-foot,  97. 

Manipulative  treatment  of  con- 
genital club-foot,  126. 

Mayo,  C.  H.,  on  treatment  of 
hallux  valgus,  261. 

Medio-tarsal  joint,  movements 
at,  46. 

Mensuration  of  tuberculous  foot, 
222. 

Metatarsal  bones,  the,  18. 
joints,  manipulation  of,  loi. 

Metatarsalgia,    251. 

Morton's  toe,  253. 

Movements  of  the  foot,  43. 

Murphy,  J.  K.,  on  congenital  de- 
formities of  the  tibia  and  fe- 
mur, 143. 

Muscles,   changes   in,   in  talipes 
equino-varus,  120. 
of  the  calf,  24. 
of  the  foot,  23. 

Muscular  spasms  in  tuberculous 
foot,  221, 

Myasthenia  angio-sclerotica,  264. 

Myers  wrench,  154. 

Nerves  of  the  foot,  39. 
Neurotomy  for  spastic  paralysis, 

180. 
Nutt's  traction  shoe,  73. 


290 


INDEX 


Ogston'6     operation — arthrodesis 
of      the      astragalo-sca- 
phoid  joint,  107,  176. 
Onychia,  272. 

Operation  for  hallux  valgus,  260. 
hammer-toe,  262. 
shortened  heel-cord,  250. 
tuberculous  foot,  238. 
Ogston's  arthrodesis,  107. 
tenotomy  for  flat-foot,  106. 
tenotomy  of  tendo  Achillis,  'j^. 
Operative  treatment  of  congeni- 
tal club-foot,  153. 
Os  calcis,  the,  17. 
Osseous  flat-foot,  84. 
Osteoclasis  for  congenital  club- 
foot, 144. 
Osteotomies,  multiple  cuneiform, 

176. 
Osteotomy    for   congenital   club- 
foot, 144. 


Pain,  significance  of  in  diagnosis, 

62. 
Painful  heel,  248. 

soles,  276. 
Palpation,  61. 

Paralysis,  infantile,  183-216. 
of  plantar  muscles,  198. 
of  tibialis  anticus,  201. 
residual,  183 
spastic,  178. 
Allison's  treatment,  i8r. 
Schwab's  treatment,  181. 
Stoefifel's  treatment,   181. 
treatment,  180. 
Paralytic   talipes  calcaneus,   193. 
equinus,  192. 
valgus,  191. 
varus,    191. 
Pare    on    causes    of    congenital 

club-foot,  116. 
Parker   on  causes  of  congenital 
club-foot,  116. 


Parker  on  tenotomy  of  the  as- 
tragalo-scaphoid  capsule, 
168. 
Paronychia,  272. 
Peroneal  muscles,  27. 
Pernio  (chilblains),  265. 
Peroneus    brevis,    tenotomy    of, 
168. 
longus,  tenotomy  of,  168. 
tertius,  36. 
Phalanges,  the,  18. 
Phelps'  operation  for  congenital 

club-foot,  172. 
Physiological  laws,   Wolff's  and 

Davis',  157. 
Plantar  fascia,  21. 
fascia,  tenotomy  of,  169. 
flexion,  30-32. 

of  the  foot,  43. 
ligaments,  21. 
muscles,  paralysis  of,  198. 
neuralgia,  268. 
Plaster-of-Paris      dressing      for 
flat-foot,  103. 
for  congenital  club-foot,  137. 
Policeman's  heel,  248. 
Post-operative  treatment  of  flat- 
foot,  108. 
Posterior  ligament,  22,. 
Pott's    disease,    complicated    by 
paralysis,  178. 

Radiography  of  tuberculous  foot, 

222. 
Raynaud's   disease,  262. 
Residual  paralysis,  183. 

Scaphoid,  the,  17. 
Scaphoidectomy  for  flat-foot,  108. 
Scarpa  on   causes  of  congenital 

club-foot,  116. 
Schwab's    treatment    of    spastic 

paralysis,   181. 
Sea-bathing  for  tuberculous  foot, 
236. 


INDEX 


291 


Sesamoid  bones,  the,  18. 
Shattock  on  causes  of  congenital 

club-foot,  116. 
Shaffer's  brace,  96. 
Shaffer's  foot,  65-77. 

etiology,  ^2. 

characteristics,  65-67. 

symptoms,  68. 

treatment,  72. 
Shaffer's  liniment,  no. 

traction  shoes,   72,  202, 
Shoe,  lateral  traction,  203. 

Nutt's  traction,  73. 

Shaffer's  traction,  72. 

the  Beely-heel,  88, 

Willard's,  139. 
Shoes,  the  heels,  280. 

importance    of   proper   fitting, 
284. 

the  toes,  280. 

the  uppers,  283. 

the  shank,  281. 

the  rocker-sole,  284. 
Silk  ligaments,  use  of  in  paralysis 

of  foot,  212. 
Sinuses,  tuberculous,  240. 
Skeleton  of  the  foot,  18. 
Soles,  painful,  276. 
Spastic  paralysis,  178. 
Standing,  proper  position,  57. 
Stockings,  277. 
Stoeffel's    treatment    of    spastic 

paralysis,  181, 
Strapping    weak-foot    with    ad- 
hesive plaster,  100. 
Stromeyer  on  subcutaneous  ten- 
otomy, 161. 
Sub-astragaloid      joint,      move- 
ments at,  45. 
Subcutaneous  tenotomy,  161. 
Sun-bath    for    tuberculous    foot, 

235- 
Sweating  feet,  266. 
Symptoms  of  Shaffer's  foot,  68. 


Talipes    calcaneo-valgus,    defini- 
tion  of,   III. 
calcaneo-varus,    definition    of, 

III. 
calcaneus,     congenital,     treat- 
ment, 151. 
definition  of,  in. 
paralytic,  193. 
cavus,  congenital,  153. 
comparative   frequency  of  va- 
rieties, 114. 
equino-cavus,  congenital,  153. 
equino-valgus,  congenital,  treat- 
ment, 150. 
definition  of,  iii. 
equino-varus,  changes  in  bones 
in,    118. 
changes  in  muscles  and  liga- 
ments in,  120. 
confirmation     of     structural 

changes  in,  123. 
definition  of,  in. 
early  treatment,  125-145. 
general  appearance,  116. 
pathological  changes  in,  148. 
treatment  when  child  begins 
to  stand,  146-150. 
equinus,  congenital,  treatment, 
ISO. 
definition  of,  iix. 
paralytic,  192. 
planus,  congenital,  153. 
varus,     congenital,     treatment, 
151. 
definition  of,  in. 
paralytic,  191. 
valgo-cavus,  congenital,   153. 
valgus,    congenital,    treatment, 

150. 
valgus   and   varus,   congenital, 

treatment,  152. 
valgus,  definition  of,  in. 
paralytic,  191. 


292 


INDEX 


Tamplin   on   frequency  of  club- 
foot, 113. 
Tarsectomy,  cuneiform,  176. 

for  fiat-foot,  107. 
Taylor's  club-foot  brace,  140. 
Tendo  Achillis,  26. 
contraction  of,  64. 
tenotomy  of,  76,  163. 
transplantation,  209. 
Tendons  of  the  foot,  23. 
Tenotomy  for  flat-foot,  106. 
for  spastic  paralysis,   180. 
indications  for,  170. 
of  astragalo-scaphoid   capsule, 

168. 
of  flexor  longus  digitorum,  168. 
of  peroneus  longus  and  brevis, 

168. 
of  plantar  fascia,  169. 
of  tendo  Achillis,  76,  163. 
of  tibialis  anticus,  168. 
of  tibialis  posticus,  166. 
subcutaneous,  161. 
Therapeutics  of  early  treatment 

of  congenital  club-foot,  145. 
Thomas  knee  brace,  229. 

wrench,  154. 
Tibialis  anticus,  35. 
paralysis  of,  201. 
tenotomy  of,  168. 
posticus,  34. 

tenotomy  of,  166. 
Toe-walking,  55. 
Traction  shoes,  Shaffer's,  72. 
Transversus  pedis,  the,  38. 
Treatment,    Bier's,    for   tubercu- 
lous foot,  231. 
constitutional,  for  tuberculous 

foot,  237. 
callosities,  275. 
chilblains,  265. 

congenital  club-foot,  125-177. 
early,  125, 
manipulation,  126. 


Treatment,   congenital  club-foot 
apparatus,  130. 

muslin  bandages,  130. 
adhesive  plaster,  131. 
braces,  131. 
felt  splint,  133. 
wood  splint,  136. 
plaster-of-Paris,   137. 
Willard's  shoe,  139. 
Taylor's  brace,  140. 
osteotomy,  144. 
osteoclasis,  144. 
therapeutics  of,  145. 
when  child  begins  to  stand, 

146. 
operative  procedure,  153-172. 
wrenching,  153. 
tenotomy,  1 61-172. 

indications  for,  170. 
Phelps'  operation,  172. 
bone  operations,  172. 
astragalectomy,  174. 
Ogston's  operation,  176. 
cuneiform  tarsectomy,  176. 
multiple     cuneiform     osteo- 
tomies, 176. 
congenital     talipes     calcaneus, 

151. 
congenital    talipes    equino-val- 

gus,  150. 
congenital  talipes  equinus,  150. 
congenital  talipes  valgus,  150. 
congenital  talipes  varus,  151. 
corns,  270. 
fallen  arch,  253. 
flat-foot,  86. 
frost-bite,  266. 
hallux  valgus,  257. 
hammer-toe,  261. 
gonorrheal    infection    of    the 

foot,  245. 
infantile  paralysis,  202. 
instrumental  stretching,  202. 
lateral  traction  shoe,  203. 


INDEX 


293 


Treatment  of  infantile  paralysis, 
braces,  206. 
wedge  sole,  20Q. 
tendon   transplantation,   209. 
silk  ligaments,  212. 
astragalectomy,  213. 
ingrowing  toe-nail,  273. 
intermittent  limping,  264. 
metatarsalgia,  253. 
Morton's  toe,  256. 
painful  heel,  249. 
perforating  ulcer  of  the  foot, 

264. 
Raynaud's  disease,  263. 
Shaffer's  foot,  72. 
shortened  heel-cord,  250. 
sinuses,  240. 
spastic  paralysis,  179. 
sweating  feet,  267. 
tuberculous  abscesses,  240. 
tuberculous  disease  of  the  foot, 

225. 
tuberculous  joints,  242. 
tuberculin,      for      tuberculous 

foot,  233. 
weak-foot,  86. 
Tubby  on  astragalectomy,  174. 
Tubbyj  on  talipes   equino-varus, 

148. 
Tuberculin  test   for  tuberculous 

foot,  223. 
Tuberculin  treatment  for  tuber- 
culous   disease    of    the 
foot,  233. 
Tuberculous  foot,  diagnosis,  217, 
mensuration,  222. 


Tuberculous  foot — Continued. 
muscular    spasms   in,    220. 
primary  focus,  217. 
joints,  242. 

Ulcers  of  the  foot,  264. 

Vaccine  treatment  for  gonorrheal 
infection  of  the  foot,  246. 

Volkman,  on  causes  of  congeni- 
tal club-foot,  116. 

Walking,  54. 

Weak-foot,       adhesive      plaster 
strapping,   100. 
characteristics,  78. 
diagnosis,  79. 
exercises  for,  89. 
manipulations  for,  97. 
treatment,  83. 
Wedge  sole,  209. 
Weight,   distribution   of   on   the 

feet,  41. 
Whitman  on  congenital  deformi- 
ties, 113. 
Whitman's  astragalectomy,  213. 

brace,  94. 
Willard,   on   early  treatment   of 

club-foot,  125. 
Willard's  shoe,  139. 
Wolff's  physiological  law,  157. 
Wood  splint  for  congenital  club- 
foot, 136. 
Work,  rest  and  fatigue,  51. 
Wrenching    in    operative    treat- 
ment of  club-foot,  153. 


Practical  Monographs 

DISEASES  AND   DEFORMITIE-S    OF 
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